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Background: Adults with cerebral palsy (CP) are a largely understudied, growing population with unique health care requirements. We sought to establish a deeper understanding of the surgical risk in adults with CP undergoing a common general surgical procedure: cholecystectomy., Methods: Data were obtained from the State Inpatient Database developed for the Healthcare Cost and Utilization Project. Inclusion criteria included patients ≥ 18 years with CP and a primary ICD-9 procedure code indicating open or laparoscopic cholecystectomy. Demographics, procedure-related factors, and comorbid conditions were analyzed, and unplanned 30 and 90 day readmission rates calculated for each variable. Reasons for readmission based on ICD-9 diagnosis codes were grouped into relevant categories. Univariate analysis identified factors significantly associated with readmission rates., Results: A total of 802 patients with CP met the inclusion criteria. Unplanned 30 and 90 day readmission rates after laparoscopic cholecystectomy were 11.4% and 18.1%, respectively. Average length of stay (LOS) after laparoscopic cholecystectomy was 7.1 days. After open cholecystectomy, 30 and 90 day readmission rates were 16.9% and 30.3% with an average LOS of 14.6 days. Infection was the most common cause for 30 and 90 day readmission. Factors associated with 30 day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid diabetes and malnutrition. Factors associated with 90 day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid heart failure, renal disease, epilepsy, and malnutrition., Conclusion: Unplanned readmission rates after open and laparoscopic cholecystectomy in adult patients with CP are much higher than previously demonstrated rates in the general population. These patients frequently suffer multiple comorbid conditions that significantly complicate their surgical care. As more and more of these patients live longer into adulthood, further study is warranted to grasp the perioperative risk of simple and complex surgical procedures., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied., Methods: We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization., Results: Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001)., Conclusions: The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques., (© 2024. The Author(s).)

Background: Robotic cholecystectomy is being increasingly used for patients with acute gallbladder disease who present to the emergency department, but clinical evidence is limited. We aimed to compare the outcomes of emergent laparoscopic and robotic cholecystectomies in a large real-world database., Methods: Patients who received emergent laparoscopic or robotic cholecystectomies from 2020 to 2022 were identified from the Intuitive Custom Hospital Analytics database, based on deidentified extraction of electronic health record data from US hospitals. Conversion to open or subtotal cholecystectomy and complications were defined using ICD10 and/or CPT codes. Multivariate logistic regression with inverse probability treatment weighting (IPTW) was performed to compare clinical outcomes of laparoscopic versus robotic approach after balancing covariates. Cost analysis was performed with activity-based costing and adjustment for inflation., Results: Of 26,786 laparoscopic and 3,151 robotic emergent cholecystectomy patients being included, 64% were female, 60% were ≥45 years, and 24% were obese. Approximately 5.5% patients presented with pancreatitis, and 4% each presenting with sepsis and biliary obstruction. After IPTW, distributions of all baseline covariates were balanced. Robotic cholecystectomy decreased odds of conversion to open (odds ratio, 0.68; 95% confidence interval, 0.49-0.93; p = 0.035), but increased odds of subtotal cholecystectomy (odds ratio, 1.64; 95% confidence interval, 1.03-2.60; p = 0.037). Surgical site infection, readmission, length of stay, hospital acquired conditions, bile duct injury or leak, and hospital mortality were similar in both groups. There was no significant difference in hospital cost., Conclusion: Robotic cholecystectomy has reduced odds of conversion to open and comparable complications, but increased odds of subtotal cholecystectomy compared with laparoscopic cholecystectomy for acute gallbladder diseases. Further work is required to assess the long-term implications of these differences., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical clips are commonly used during laparoscopic cholecystectomy for cystic duct and artery ligation. Titanium and polymer clips are the two most common types used for this indication. Given the cost-saving potential, design advantages, and decreased incidence of complications associated with polymer clips, we sought to study whether there is a clinically significant difference in outcome between polymer and titanium clips in laparoscopic cholecystectomy., Methods: Fifty consecutive cases using polymer clips followed by 50 consecutive cases using metal clips over a 6-month period by residents under the direction of a single surgeon were retrospectively reviewed. The following outcomes were evaluated: incidence of bile leak, postoperative bleeding, need for additional procedures, hospital length of stay, and cost., Results: We found that significantly more misfires occurred with the use of the polymer clips (n=17) than with the titanium clips (n=2, p<.001). Eight cases (16%) required opening of an additional polymer clip cartridge to complete the operation. Despite this additional expense, the total cost as it pertained to clip usage ($30.32 USD) was still lower than that using titanium clips ($139.17 USD). While these numbers were not statistically significant, three cases had bile leaks and required additional procedures, all of which were performed with metal clips. No postoperative bleeds were identified and there was no difference in hospital length of stay; most patients were discharged on the day of the procedure., Conclusion: These findings demonstrate comparable clinical outcomes between laparoscopic cholecystectomies performed with polymer and titanium clips, though polymer clip usage carries a lower cost.

Background Laparoscopic Cholecystectomy (LC) is the gold-standard surgery for symptomatic cholelithiasis with low mortality and morbidity. Objective The main objective of this study is to study the outcomes of laparoscopic cholecystectomy in Dhulikhel Hospital over the period of seven years. Method The records of all the patients who underwent laparoscopic cholecystectomy in Dhulikhel Hospital from January 1, 2015, to December 31, 2021 were reviewed. Patient demographics, indication of surgery, hospital stay, and number of conversions to open cholecystectomy were collected. The percentage, mean and median were calculated for socio-demographic information and Chi-square test was performed to measure the association between socio-demographic characteristics, duration of hospital stay, and operative procedure. Result Out of 2106 patients who underwent laparoscopic cholecystectomy from January 1, 2015, to December 31, 2021, 584 (27.73%) were male, and 1522 (72.27%) were female. The female-to-male ratio was 2.6:1. The median age of the patients was 40 years (IQR=52-30). Most common indications for surgery were symptomatic cholelithiasis in 1740 (82.62%) patients along with chronic cholecystitis in 268 (12.73%) patients, and Post ERCP Cholecystectomy in 92 (4.37%) patients. Median hospital stay was three days. Out of 2106 cases, 24 cases were converted to open cholecystectomy. Conclusion Laparoscopic cholecystectomy is the gold standard treatment for benign diseases of the gallbladder and can be performed safely as day care surgery to reduce the cost, length of hospital stay, and long waiting list in low and middle-income countries.

Background: Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients., Methods: Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed., Results: In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001)., Conclusions: Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery., Competing Interests: Declaration of competing interest The authors have no financial or personal relationships with other people or organizations that could influence this work., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Although gallbladder disease is more common in women, there is a trend toward more complicated cases in male patients., Methods: All cholecystectomies captured by the National Surgical Quality Improvement Program database for the year 2016 were reviewed. This encompassed 38 736 records. Records were reviewed for age, sex, procedure performed, operative time, postoperative diagnosis, functional status, American Society of Anesthesiologists (ASA) class, preoperative lab values (total bilirubin, alkaline phosphatase, white blood cell count, and aspartate aminotransferase. Descriptive and inferential statistical analyses were conducted., Results: Male patients are more likely to undergo cholecystectomy for a diagnosis of cholecystitis, gallstone pancreatitis, or cholangitis than women who are more likely to carry a diagnosis of biliary dyskinesia. The average operative time increases for both sexes as the patients become older. The average operative time is higher for men than women in all age groups and the variance becomes greater as the patients become older. Age, sex, postoperative diagnosis, ASA class, and functional status were all independently significant in predicting operative time. There was no difference in need for cholangiogram between the sexes. Female patients were more likely to have their cholecystectomy completed laparoscopically and they were more likely to have their surgery performed as an outpatient., Conclusion: These data show that women were more likely to present with uncomplicated gallbladder disease, while men were more likely to present with complicated gallbladder disease. This suggests that male patients present at a more advanced stage of disease.

Background: Postoperative nausea and vomiting (PONV) is an undesirable complication in patients undergoing general anesthesia. Combination therapy via different mechanisms of action for antiemetic prophylaxis has been warranted for effective treatment of PONV. This study was designed to compare the prophylactic antiemetic effect between midazolam combined with palonosetron (group MP) and palonosetron alone (group P) after laparoscopic cholecystectomy surgeries., Methods: A prospective randomized controlled trial was investigated in non-smoking female. Eighty-eight patients were randomly divided into 2 groups with 44 patients each. Group MP received 0.05 mg/kg of midazolam intravenously before induction of anesthesia whereas group P received the same volume of normal saline. Immediately after anesthetic induction, 0.075 mg of palonosetron was administered to both the groups. The incidence and severity of PONV were assessed during 2 time intervals (0-2 hours, 2-24 hours), postoperatively., Results: The incidence of PONV during 24 hours after surgery was lower in group MP as compared to group P. There was also a significant difference in the use of rescue antiemetics. The severity of nausea was significantly lower in group MP as compared to group P, in the initial 2 hours after surgery. The incidence of side effects was similar between the 2 groups., Conclusion: In the prevention of PONV, midazolam combined with palonosetron, administered during induction of anesthesia was more effective as compared to palonosetron alone., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services., Methods: We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications., Results: This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03)., Conclusions: With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences., (Copyright © 2021. Published by Elsevier Inc.)

Background: Laparoscopic cholecystectomy (LC) is one of the safest, most commonly performed surgical procedures, but postoperative complications including bile leak, retained stone, cholangitis, and gallstone pancreatitis following LC occur in up to 2.6% of cases and may require readmission with possible endoscopic retrograde cholangiopancreatography (ERCP) intervention. There is a paucity of literature on factors predictive of need for ERCP following LC. The goal of this study is to describe the prevalence and risk factors for readmission with indication for ERCP., Methods: We queried the ACS/NSQIP 2012-2017 Participant User Files for patients who underwent LC. Patient demographics, comorbidities, operative characteristics, and postoperative outcomes were evaluated. Multivariate logistic regression was used to identify risk factors for readmission with indication for ERCP intervention., Results: Of 275,570 patients, 11,010 (4.00%) were readmitted within the 30-day postoperative period. Among these, 930 (8.44%) were admitted with indication for ERCP intervention. On multivariate regression, readmissions were more likely in older patients, inpatients, and patients with baseline comorbidities, acute preoperative morbidity, and those discharged to care facilities. The use of intraoperative cholangiogram was associated with lower odds of readmission. Less than 10% of readmitted patients had an indication for ERCP. Those who were readmitted with an indication for ERCP were more likely to have undergone emergency surgery, experienced longer operative times, and had elevated preoperative LFTs or gallstone pancreatitis prior to surgery. The risk of 30-day mortality was significantly higher among patients who experienced any complications after their surgery (OR 13.03, 95% CI 10.57-16.07, p < 0.001)., Conclusions: Older patients, patients with greater preoperative morbidity, and those discharged to care facilities were more likely to be readmitted for any reason following laparoscopic cholecystectomy, whereas patients with evidence of complicated gallstone disease were more likely to be readmitted with an indication for ERCP, even when controlling for the use of intraoperative cholangiogram. Initiatives aimed at reducing readmission with indication for ERCP should focus on these patient subgroups.

Background: A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both., Methods: Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined., Results: Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy., Conclusion: Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aim: This study aims to evaluate the incidence, indications, management, and long term follow up of cholecystectomy in patients with no gallstones, other than acalculous acute cholecystitis., Methods: Prospectively collected data of 5675 patients undergoing laparoscopic cholecystectomy (LC) over 28 years was extracted and analyzed. Patients with biliary symptoms, no stones on ultrasound scans and abnormal hepatobiliary iminodiacetic acid scans, and those with confirmed gallbladder polyps (GBP) were included., Results: Two percent of cholecystectomies were performed in patients with acalculous pathology [1.3% functional gallbladder disorder (FGBD) and 0.7% GBP]. The 114 patients were younger, had lower American Society of Anesthesiologists classification, and had fewer previous biliary admissions than those with gallstones (5560). The clinical presentations of FGBD were chronic biliary symptoms (93.1%) and acute biliary pain (6.9%). GBP patients presented with chronic biliary symptoms. LC in 98.6% FGBD and 92.8% GBP were significantly easier than those for gall stones (P < 0.0001). They were significantly (P < 0.0001 FGBD and P < 0.001 GBP) less likely to have adhesions to the gallbladder. This ease was reflected in shorter operation times and lower utilization of abdominal drains. Polyp numbers ranged from 1 to 30 and sizes from 1 mm to 11 mm. No malignant polyps were encountered. In 95.8% FGBD and 95% GBP, patients had a good symptomatic response to LC., Conclusions: FGBD and GBP are uncommon in patients undergoing LC. FGBD should be considered during evaluation of right upper quadrant pain with no gall stones. Laparoscopic cholecystectomy may be considered as it achieves long term symptomatic relief in most patients with FGBD and GBP., Competing Interests: Conflicts of interest: none., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Background: The UK practice of laparoscopic cholecystectomy has reduced during the COVID-19 pandemic due to cancellation of non-urgent operations. Isolated day-case units have been recommended as 'COVID-cold' operating sites to resume surgical procedures. This study aims to identify patients suitable for day case laparoscopic cholecystectomy (DCLC) at isolated units by investigating patient factors and unexpected admission., Method: Retrospective analysis of 327 patients undergoing DCLC between January and December 2018 at Ysbyty Gwynedd (District General Hospital; YG) and Llandudno General Hospital (isolated unit; LLGH), North Wales, UK., Results: The results showed that 100% of DCLCs in LLGH were successful; 71.4% of elective DCLCs were successful at YG. Increasing age ( p  = 0.004), BMI ( p  = 0.01), ASA Score ( p  = 0.006), previous ERCP ( p  = 0.05), imaging suggesting cholecystitis ( p  = 0.003) and thick-walled gallbladder ( p  = 0.04) were significantly associated with failed DCLC on univariate analysis. Factors retaining significance (OR, 95% CI) after multiple regression include BMI (1.82, 1.05-3.16; p  = 0.034), imaging suggesting cholecystitis (4.42, 1.72-11.38; p  = 0.002) and previous ERCP (5.25, 1.53-18.00; p  = 0.008). Postoperative complications are comparable in BMI <35kg/m 2 and 35-39.9kg/m 2 ., Conclusions: Current patient selection for isolated day unit is effective in ensuring safe discharge and could be further developed with greater consideration for patients with BMI 35-39.9kg/m 2 . As surgical services return, this helps identify patients suitable for laparoscopic cholecystectomy at isolated COVID-free day units.

Background: Erector spinae plane (ESP) block is a novel regional anesthetic technique. Its application for postoperative analgesia has been increasing since 2016; however, its effectiveness remains uncertain and varies according to the type of surgery. This meta-analysis aimed to assess the analgesic efficacy of ESP block in patients undergoing laparoscopic cholecystectomy., Methods: Literature searches of electronic databases and manual searches up to June 1, 2020 were performed. Review Manager Version 5.3 was used for pooled estimates. We included only randomized controlled trials (RCTs) in this meta-analysis. The random-effects meta-analysis model was used, and metaregression was applied when appropriate., Results: A total of five RCTs consisting of 250 patients were included (124 in the ESP block group vs. 126 in the control group). Bilateral ESP block showed a significant reduction in postoperative intravenous opioid consumption reported up to 24 hours after surgery (mean difference [MD] = -4.46, 95% confidence interval [CI] [-5.50 to -3.42], P < 0.001) and in the time to first rescue analgesic (MD = 73.27 minutes, 95% CI [50.39 to 96.15], P < 0.001). According to the results of four studies, the postoperative pain score was lower in the ESP group compared with the control group at both rest and movement. There were no differences between the two groups as concerns nausea (odds ratio [OR] = 0.45, 95% CI [0.13 to 1.52], P = 0.20) and vomiting (OR = 0.37, 95% CI [0.10 to 1.35], P = 0.13). No block-related complications were noted., Conclusion: This meta-analysis showed that bilateral ultrasound-guided ESP block could be considered as an effective option to reduce opioid consumption and the time to first rescue analgesic and seems to be also a safe technique in adults undergoing laparoscopic cholecystectomy., (© 2020 World Institute of Pain.)

Background: Cholecystectomy trends and outcomes have been reported extensively in the private sector. Despite being one of the most common procedures performed in the United States, there is a paucity of reports on the trends and outcomes of laparoscopic and open cholecystectomy in the veteran population. Materials and Methods: Veterans who underwent laparoscopic or open cholecystectomy from 2006 to 2017 were identified using current procedural terminology codes from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Multivariable analyses were used to compare laparoscopic and open outcomes. The primary outcome was mortality, and secondary outcomes were postoperative complications and length of stay (LOS). Results: In the VASQIP database, 53,901 patients underwent laparoscopic cholecystectomy and 8011 patients underwent open cholecystectomy during the study period. The laparoscopic approach increased from 82.0% (2006-2008) to 91.9% (2015-2017). Postoperatively, the open group had a significantly higher morbidity rate (15.4% versus 3.8%, P  < .001). The 30-day mortality rate and mean LOS were also significantly higher in the open cholecystectomy group ( P  < .001). Earlier year of operation, diabetes diagnosis, and open approach significantly increased the likelihood of postoperative morbidity ( P  < .05). Conclusions: Similar to the private sector, minimally invasive cholecystectomy in the Veterans Health Administration (VHA) has increased over the last two decades. Diabetes was present in a significant percentage of the veteran population and was a predictor of all postoperative complications. Finally, the clinical outcomes in the VHA are comparable with those documented in the private sector.

Objectives: Laparoscopic cholecystectomy (LC) following acute gallstone cholangitis reduces the recurrence of biliary symptoms; however, the timing of LC has not been determined yet. The aim of our study was to evaluate the impact of performing LC during admission on the 30-day readmission rate., Methods: We conducted a retrospective cohort study of acute gallstone cholangitis patients who underwent endoscopic clearance (EC) of the bile duct through endoscopic retrograde cholangiopancreatography between April 2013 and May 2018. Patients were classified into two groups: EC only group and EC followed by LC during admission (EC + LC) group. The primary outcome was the 30-day readmission rate., Results: A total of 95 patients with acute cholangitis were included in the analysis. Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the EC + LC group compared to the EC group (2.9% vs. 26.7%, P 0.003). In a multivariate regression analysis, patients who underwent LC during admission had 90% lower odds of readmission within 30 days compared to patients who did not (OR 0.1, 95% CI (0.01-0.9), P 0.04)., Conclusions: Performing laparoscopic cholecystectomy during admission for acute gallstone cholangitis patients following endoscopic clearance of the bile duct significantly reduced the 30-day readmission rate without affecting the length of stay.

Background: The use of indocyanine green during laparoscopic cholecystectomy has been postulated to help to define anatomy. Studies have not specifically evaluated patients with acute cholecystitis. We sought to assess whether use of indocyanine green can decrease the rate of bail-out operation (subtotal cholecystectomy or conversion to an open operation) in an acute care surgery population where acute cholecystitis is more frequent., Methods: Using a retrospective cohort design, we examined all inpatient cholecystectomies performed by the acute care surgery service under urgent or semiurgent (biliary colic as the presentation in the emergency room) conditions at a single institution from 7/1/18 to 6/30/19 during which indocyanine green was available for use at the surgeon's discretion., Results: A total of 198 patients were included in the analysis. Demographic variables were similar in groups receiving indocyanine green versus not. Pathology confirmed acute cholecystitis was present in 96 of 198 (48.5%) patients; of those, 55 (57.2%) received indocyanine green. Indocyanine green did not change the rate of bail-out operation between patients who received indocyanine green and those who did not (6.7% vs 4.3%, P = .468). No significant differences in complications were observed. Bail-out operation was more likely in cases of acute cholecystitis (9.4%) versus nonacute cholecystitis (2.0%) (odds ratio = 5.172, P = .039). In patients with acute cholecystitis, indocyanine green did not change the rate of bail-out operation (indocyanine green: 12.7% vs no indocyanine green: 4.9%, P = .293)., Conclusion: This is the first series looking at the use of indocyanine green specifically in an acute care surgery population. Indocyanine green did not decrease operative time or need for a bail-out operation in acute cholecystitis. Further study is needed to determine whether indocyanine green use is justified in this population., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.

Background: Wound infiltration analgesia provides effective postoperative pain control in patients undergoing laparoscopic cholecystectomy (LC). However, the efficacy and safety of wound infiltration with different doses of ropivacaine is not well defined. This study investigated the analgesic effects and pharmacokinetic profile of varying concentrations of ropivacaine at port sites under laparoscopy assistance., Methods: In this randomized, double-blinded study, 132 patients were assigned to 4 groups: Group H: in which patients were infiltrated with 0.75% ropivacaine; Group M: 0.5% ropivacaine; Group L: 0.2% ropivacaine; and Group C: 0.9% normal saline only. The primary outcome was pain intensity estimated using numeric rating scale (NRS) at discharging from PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration. Secondary outcomes included plasma concentrations of ropivacaine at 30 minutes after wound infiltration, rescue analgesia requirements after surgery, perioperative vital signs changes, and side effects., Results: The NRS in Group C was significantly higher at rest, and when coughing upon leaving PACU and at 4 hours, 6 hours, 8 hours, and 24 hours after infiltration (P < .05) and rescue analgesic consumption was significantly higher. Notably, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). Intra-operative consumption of sevoflurane and remifentanil, HR at skin incision and MAP at skin incision, as well as 5 minutes after skin incision were significantly higher in Group C than in the other 3 groups (P < .01). In contrast, these parameters were not significantly different between Groups H, Group M and Group L (P > .05). The concentration of ropivacaine at 30 minutes after infiltration in Group H was significantly higher than that of Group L and Group M (P < .05). No significant differences were observed in the occurrence of side effects among the 4 groups (P > .05)., Conclusions: Laparoscopy-assisted wound infiltration with ropivacaine successfully decreases pain intensity in patients undergoing LC regardless of the doses used. Infiltration with higher doses results in higher plasma concentrations, but below the systematic toxicity threshold.

Background: Gallstone disease is a common problem and laparoscopic cholecystectomy (LC) is a common elective procedure. This operation was performed by a general surgeon, colorectal surgeons, breast and vascular surgeons according to the largest UK's audit (CholeS study). Objectives: To compare the outcomes of laparoscopic cholecystectomy performed by a specialist upper gastrointestinal (UGI) surgeon to that of CholeS and large international studies. Our hypothesis is: UGI specialist is producing better outcomes for LC patients. Methods: All patient who underwent LC between 1999 and 2019 at one hospital by an UGI consultant and 2014-2019 at another hospital by another UGI consultant surgeon were included. The inclusion criteria were LC performed by UGI surgeon. Lost to follow up, procedures done by trainees and gallbladder cancer patients were excluded. The outcome measures of bile leak, bile duct injuries, bleeding, infectious complications, bowel injuries, vascular injuries and pseudoaneurysms, neuralgia, port site hernia, mesenteric haematoma, 30-day mortality and conversion to open were reported. Statistical tests were used to assess the significant differences, the confidence interval was 95% and the p-value was taken as 0.05. Results: Two UGI specialists performed 5122 LC, 4396 (86%) were female and 715 (14%) male. The age was 13-93 year (median of 48 years). 3681 (72 %) was done as a day surgery case. 1431(28%) as an inpatient and 287 (5.6%) emergency LC. There was no death in the 30 days periods of surgery, 8 (0.15%) biliary leak from the duct of Luschka, 4 (0.19%) common bile duct (CBD) injuries, 9(0.02%) conversions and 17(0.33%) procedures were abandoned. There were significant differences in the above complications between our study and the CholeS report. Conclusions: Laparoscopic cholecystectomy is associated with acceptable outcomes, low risk of bile duct injury and no mortality when performed by a specialist upper GI surgeon., (Celsius.)

Background: For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list., Aims: We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice., Methodology: This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS)., Results: A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16-87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality., Conclusion: Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients., Competing Interests: None

Background: Enhanced recovery after surgery (ERAS) is a perioperative bundle aimed to reduce surgical stress. Significant reductions in length of hospital stay and associated costs have been reported in multiple studies in all surgical specialties. Purpose of the study was to compare the effect of Enhanced recovery protocols vs. conventional care on perioperative length of hospital stay and cost per patient in a government funded hospital., Methods: this randomized controlled trial was conducted in the department of General Surgery, unit B, Lady reading hospital, Peshawar from April to December 2018. One hundred and fifty patients were selected based on consecutive sampling. Random allocation into two groups of 75 (ERAS vs Conventional) was done based on computer generated numbers. Length of hospital stay and total direct costs were calculated. Frequency of Surgical site infections, readmissions and mortality was also recorded. Patient reported outcomes were recorded by Surgical Recovery Scale SRS., Results: Patients in the Enhanced recovery group showed a significant reduction in length of hospital stay 28.9 hours in ERAS group vs 40.5 hours in Conventional care group (p<0.001). Total per patient cost was reduced in the ERAS group PKR 6804 in comparison to the conventional care PKR 7682 (p<0.001). Patient reported outcomes measured on Surgical Recovery Scale SRS on discharge, day 3 of discharge and day 10 of discharge showed no significant difference between the two groups., Conclusions: Enhanced recovery protocols demonstrated a reduction in length of perioperative hospital stay and total cost despite similar post discharge recovery scores on Surgical Recovery Scale SRS and no increase in readmissions.

Introduction: Common bile duct stones are present in 10% of patients with symptomatic gallstones. One-third of UK patients undergoing cholecystectomy will have preoperative ductal imaging, commonly with magnetic resonance cholangiopancreatography. Intraoperative laparoscopic ultrasound is a valid alternative but is not widely used. The primary aim of this study was to assess cost effectiveness of laparoscopic ultrasound compared with magnetic resonance cholangiopancreatography., Materials and Methods: A prospective database of all patients undergoing laparoscopic cholecystectomy between 2015 and 2018 at a district general hospital was assessed. Inclusion criteria were all patients, emergency and elective, with symptomatic gallstones and suspicion of common bile duct stones (derangement of liver function tests with or without dilated common bile duct on preoperative ultrasound, or history of pancreatitis). Patients with known common bile duct stones (magnetic resonance cholangiopancreatography or failed endoscopic retrograde cholangiogram) were excluded. Ninety-day morbidity data were also collected., Results: A total of 420 (334 elective and 86 emergency) patients were suspected to have common bile duct stones and were included in the study. The cost of a laparoscopic ultrasound was £183 per use. The cost of using the magnetic resonance cholangiopancreatography unit was £365 per use. Ten postoperative magnetic resonance cholangiopancreatographies were performed for inconclusive intraoperative imaging. The estimated cost saving was £74,650. Some 128 patients had common bile duct stones detected intraoperatively and treated. There was a false positive rate of 4.7%, and the false negative rate at 90 days was 0.7%. laparoscopic ultrasound use saved 129 bed days for emergency patients and 240 magnetic resonance cholangiopancreatography hours of magnetic resonance imaging., Conclusion: The use of laparoscopic ultrasound during laparoscopic cholecystectomy for the detection of common bile duct stone is safe, accurate and cost effective. Equipment and maintenance costs are quickly offset and hospital bed days can be saved with its use.

Background: Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis., Methods: After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression., Results: Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007)., Conclusions: Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Despite improvements in the diagnosis and care of acute pancreatitis, the mortality, morbidity, and long-term complications of this disease currently account for an annual cost of $10 billion in the United States. Lack of high-quality consolidated clinical data about this ever-increasing national and global burden makes it challenging to be able to recognize at-risk populations and intervene to avoid early readmission (ER) (i.e., readmission within 30 d of hospital discharge or ER)., Methods: We reviewed the National Readmission Database for 2016. We retrieved 25,476 ER out of a total of 188,757 patients admitted with acute pancreatitis (ICD-10 diagnosis of K85), alive at discharge. Patients younger than 18 at the time of initial admission were excluded. Diagnostic characteristics and procedures performed were extracted from ICD-10 data. Based on patient demographics and the diagnostic and procedural profiles from their initial admission, we identified clusters of risk factors for ER using agglomerative hierarchical clustering. These are depicted in a correlation matrix., Results: Acute pancreatitis is associated with a 13.5% overall ER rate. Certain pre-existing chronic diseases, particularly cardiovascular disease diagnoses and interventions at initial presentation increase the odds of ER. In contrast to interventions on the pancreas, interventions on the biliary system correlated with lower odds of ER. Furthermore, the earlier the biliary system intervention was performed during the initial hospitalization, the lower the odds of ER. We identified five clusters of interrelationships: age/comorbidity cluster, cirrhosis cluster, sepsis/pulmonary complication cluster, biliary intervention cluster, and high-risk of mortality cluster., Conclusions: We identified several potentially modifiable risk factors for ER of patients hospitalized with acute pancreatitis, which included timing of biliary interventions. Furthermore, we identified clusters of interrelationships that further illuminate which complications tend to occur concomitantly and ultimately contribute to ER. By identifying risk factors and elucidating their interactions, we have improved our understanding of this highly morbid disease and offer potential points of intervention to reduce ER., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The incidence of bile duct injury (BDI) during laparoscopic cholecystectomy has not changed significantly in the past 2 decades despite increased operative experience and technical refinement. We sought to evaluate surgeon-specific factors associated with BDI and to assess how surgeons manage injuries., Methods: An online survey was sent to surgeons belonging to the Society of American Gastrointestinal and Endoscopic Surgeons via e-mail. Survey items included personal experience with BDI and how injuries were addressed. Statistical analysis was performed to identify factors associated with BDI., Results: The survey was sent to 3411 surgeons with 559 complete responses (16.5%). The mean age of respondents was 48.7 years with an average time in practice of 16.1 years. Most respondents (61.2%) had fellowship training. Forty-seven percent of surgeons surveyed experienced a BDI in their career with 17.1% of surgeons experiencing multiple BDIs. The majority of BDIs were identified in the operating room (64.5%); most injuries (66.9%) were repaired immediately. When repair was undertaken immediately, 77.4% of these repairs were performed in an open technique. A majority of surgeons (57.7%) felt that BDIs could theoretically be repaired laparoscopically and 25% of those surgeons had done so in practice. In multivariate logistic regression, any type of fellowship training was associated with a decreased risk of BDI (OR 0.51, 95% CI 0.34-0.76). Compared with those in non-academic practice, surgeons in academic practice were at a significantly decreased risk of having experienced a BDI (OR 0.62, 95% CI 0.42-0.92)., Conclusion: Nearly half of those surveyed, experienced a BDI during a laparoscopic cholecystectomy. Community and private practice setting were associated with an increased risk of BDI, while fellowship training and academic practice setting conferred a protective effect. A majority of surgeons felt that BDI could be repaired laparoscopically and 25% had done so in practice.

Background: Early cholecystectomy following an episode of gallstone pancreatitis is data supported, however, there is minimal literature regarding the optimal timing for cholecystectomy following an episode of acute cholangitis. Our study aims to determine the ideal timing for laparoscopic cholecystectomy following an episode of acute cholangitis., Methods: A retrospective chart review was done on cholecystectomies performed for cholangitis at our institution from 2008 to 2015. Patients were compared based on timing of cholecystectomy (i.e., index admission versus delayed) and Tokyo severity grade (I-III)., Results: We identified 151 patients who underwent cholecystectomy for cholangitis at our institution from 2008 to 2015. Cholecystectomy was performed during the index admission for 61.6% of patients and Tokyo grade (TG) did not affect the rate of cholecystectomy during index admission (TG1 65.2%, TG2 64.1%, TG3 52.8%; p = 0.46). There was no difference in average operative time (89.0 min vs. 96.6 min; p = 0.36) or conversion to open cholecystectomy (5.4% vs. 10.3%; p = 0.34) between early and late cholecystectomy groups. There was also no statistically significant difference in intra-operative complications (9.7% vs. 15.5%; p = 0.28) or overall complication rates (16.1% vs. 29.3%; p = 0.05) based on timing of cholecystectomy; however, post-operative complications were significantly higher for the delayed cholecystectomy group (20.7% vs. 6.5%; p = 0.01)., Conclusions: Early cholecystectomy after cholangitis is safe to perform and is not associated with higher operative times or rate of conversion to open, regardless of Tokyo grade. Due to the risk of developing recurrent cholangitis and a higher rate of post-operative complications seen with delayed cholecystectomy, our recommendation is to perform cholecystectomy during the index admission.

Background: Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy., Methods: We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression., Results: On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced., Conclusions: Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.

Biliary injury is a rare but a very serious complication of laparoscopic cholecystectomy (LC). Our aim was to analyse the incidence of the biliary injuries and its therapeutic outcome on patients who underwent LC or converted LC. Our research was conducted at the 1st Department of Surgery, Semmelweis University, Budapest between 2006 and 2016, retrospectively. We analysed the LCs and converted LCs performed at our Department and as well as cases where the primary operations were conducted at other institutions but they were unable to provide the adequate therapy for the injury, thus the patients were transferred to our institution. At the 1st Department of Surgery complications occurred in 0,66% (30/4885) of all LCs. 327 converted LCs were done, complications occurred in 26 (7.95%) times. 22 patients were transferred to the 1st Department of Surgery from other institutions. Bilio-vascular injuries occurred in 61% (41/78). ERCP was performed in 25 cases with a 92% success rate. Reoperation was needed in 41% (28/41). Biliary reconstruction during the reoperation was performed via hepaticojejunostomy in 82% of all reoperations. The therapeutic solutions of LC’s complications are complex. Therefore, the treatment is recommended only in institutions with appropriate experience.

Background: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC)., Methods: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume., Results: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million)., Conclusion: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value., Level of Evidence: Epidemiological, level III.

Purpose . To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons' preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods . According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: ("gallbladder" OR "cholecystectomy") AND "umbilical" AND ("epigastric" OR "subxiphoid"). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results . Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site ( P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions . This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

Background: As minimally invasive pediatric surgery becomes standard approach to many surgical solutions, access has become an important point for improvement. Laparoscopic cholecystectomy (LC) is the gold standard for many conditions affecting the gallbladder; however, open cholecystectomy (OC) is offered as the initial approach in a surprisingly high percentage of cases. Materials and Methods: The Kids' Inpatient Database (1997-2012) was searched for International Classification of Disease, 9th revision, Clinical Modification procedure code (51.2x). LC and OC performed in patients <20 years old were identified. Propensity score-matched analyses using 39 variables were performed to isolate the effects of race, income group, location, gender, payer status, and hospital size on the percentage of LCs and OCs offered. Cases were weighted to provide national estimates. Results: A total of 78,578 cases were identified, comprising LC (88.1%) and OC (11.9%). Girls were 1.6 (CI: 1.4, 1.7) times more likely to undergo LC versus boys. Large facilities were 1.4 (1.3, 1.7) times more likely to perform LCs than small facilities. Children in lower income quartiles were 1.2 (1.1, 1.3) times more likely to undergo LC compared with those in higher income quartiles. Rates of LC were not affected by race, hospital location, or payer status. Conclusions: Risk-adjusted analysis of a large population-based data set demonstrated evidence that confirms, but also refutes, traditional disparities to minimally invasive surgery access. Despite laparoscopic gold standard, OC remains the initial approach in a surprisingly high percentage of pediatric cases independent of demographics or socioeconomic status. Additional research is required to identify factors affecting the distribution of LC and OC within the pediatric population.

Introduction: Laparoscopic cholecystectomy is now considered the procedure of choice that achieves a shorter recovery period after the surgery and reduction in the cost of treatment. Aim: The aim of the study is to prove which method: early or delayed laparoscopic cholecystectomy is the method of choice in the treatment of acute cholecystitis by examining: duration of hospitalization, conversion rate, duration of surgery, postoperative complications, and total cost., Methods: The study was conducted at the University Clinical Center of Republika Srpska as a retrospective-prospective study from May 1 st 2013 until December 31 st 2019. Patients diagnosed with acute cholecystitis were divided into two groups: Patients designated for early laparoscopic cholecystectomy within 72 hours of admission (group A-42 patients), Patients designated for initial conservative treatment followed by a delayed interval of 6-12 weeks until surgery (group B-42 patients)., Results: In both groups, there were statistically significantly more female respondents. The results showed that the average cost of treatment in the early treated group was statistically significantly lower than the cost of treatment in the delayed treatment group. The patients in the early group had shorter hospitalization times (an average of 2.8 days and 5.6 days in the delayed group of patients), a smaller percentage of conversions (4.8% in the early and 16.7 in the delayed group of patients), the total cost of in the early group it was 1300.83 KM, while in the delayed group it was 1645.43 KM., Conclusion: Early laparoscopic cholecystectomy is a method to be preferred in surgical treatment., Competing Interests: There are no conflicts of interest., (© 2020 Goran Janjic, Milan Simatovic, Velimir Skrbic, Reuf Karabeg, Dragan Radulj.)

Background: As robotic surgery becomes more ubiquitous, determining clinical benefit is necessary to justify the cost and time investment required to become proficient. We hypothesized that robotic cholecystectomy would be associated with improved clinical outcomes but also increased cost as compared with standard laparoscopic cholecystectomy., Materials and Methods: All patients undergoing robotic or laparoscopic cholecystectomy at a single academic hospital between 2007 and 2017 were identified using an institutional clinical data repository. Patients were stratified by operative approach (robotic versus laparoscopic) for comparison and propensity score matched 1:10 based on relevant comorbidities and demographics. Categorical variables were analyzed by the χ 2 test and continuous variables using the Mann-Whitney U test., Results: A total of 3,255 patients underwent cholecystectomy during the study period. We observed no differences in demographics or body mass index, but greater rates of diabetes mellitus, hypertension, and gastroesophageal reflux disease were present in the laparoscopic group. After matching (n = 106 robotic, n = 1,060 laparoscopic), there were no differences in preoperative comorbidities. Patients who underwent robotic cholecystectomy had lesser durations of stay (robotic: 0.1 ± 0.7 versus laparoscopic: 0.8 ± 1.9, P < .0001) and lesser 90-day readmission rates (robotic: 0% [0], laparoscopic: 4.1% [43], P = 0.035); however, both operative and hospital costs were greater compared with laparoscopic cholecystectomy., Conclusion: Robotic cholecystectomy is associated with lesser duration of stay and lesser readmission rate within 90 days of the index operation, but also greater operative duration and hospital cost compared with laparoscopic cholecystectomy. Hospitals and surgeons need to consider the improved clinical outcomes but also the monetary and time investment required before pursuing robotic cholecystectomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Practice variation generally raises concerns about the quality of care. This study determined the longitudinal degree of hospital variation in proportion of patients with gallstone disease undergoing cholecystectomy, while adjusted for case-mix, and the effect on clinical outcomes., Methods: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands in 2013-2015. Patients with gallstone disease were collected from the diagnosis-related group database. Hospital variation in case-mix-adjusted cholecystectomy rates was calculated per year. Clinical outcomes after cholecystectomy were compared between hospitals in the lowest/highest 20th percentile of the distribution of adjusted cholecystectomy rates in all 3 subsequent years., Results: In total, 96,673 patients with gallstones were included. The cholecystectomy rate was 73.6%. In 2013-2015, the case-mix-adjusted performance of cholecystectomies was in hospitals with high rates 1.5-1.6 times higher than in hospitals with low rates. Hospitals with a high adjusted cholecystectomy rate had a higher laparoscopy rate, shorter time to surgery, and less emergency department visits after a cholecystectomy compared to hospitals with a low-adjusted cholecystectomy rate., Conclusion: Hospital variation in cholecystectomies in the Netherlands is modest, cholecystectomy rates varies by <2-fold, and variation is stable over time. Cholecystectomies in hospitals with high adjusted cholecystectomy rates are associated with improved outcomes., (© 2020 The Author(s). Published by S. Karger AG, Basel.)

Background: Gallstones are a common cause of morbidity in the elderly. Operative treatment is often avoided due to concerns about poor outcomes but the evidence for this is unclear. We aim to consolidate available evidence assessing laparoscopic cholecystectomy outcomes in the extreme elderly (>80s) compared to younger patients. Methods: Studies comparing laparoscopic cholecystectomy in >80s with younger patients were considered. Total complications, mortality, conversion, bile duct injury, and length of stay were compared between the two groups. Results: Twelve studies including 366,522 patients were included. They were of moderate overall quality. The elderly group had more complicated gallbladder disease and also had more co-morbidities and a higher ASA grade. The risk of morbidity was lower in the younger group (RR 0.58 (95% CI 0.58-0.59)) with a slightly lower risk of conversion (RR 0.96 (0.94-0.98)) Length of stay was significantly longer for the elderly patients. Differences in mortality and bile duct injury were non-significant in all but one study. Conclusion: Laparoscopic cholecystectomy is safe and effective in the extreme elderly. Higher complication rates are predominantly related to increased co-morbidities and more complex gallbladder disease. Patients should be carefully selected, and cholecystectomy performed at an earlier stage to minimize these problems.

Background: Single-incision laparoscopic cholecystectomy (SILC) is a feasible technique that provides comparable results to standard laparoscopic cholecystectomy (LC). However, despite the theoretical advantages of minor wound complications and cosmetic results, SILC usually requires a larger incision, which may increase the incidence of incisional hernias. This study evaluated SILC and standard multiport cholecystectomy with respect to perioperative outcomes, hospital stay, cosmetic results, and postoperative complications, including the 5-year incisional hernia rate., Methods: A cohort study was performed with patients who underwent elective laparoscopic surgery for noncomplicated cholelithiasis at our hospital between July 2009 and June 2011. During the study period, there were 45 nonselected patients who underwent SILC, and these patients were compared with a control group of 140 patients who underwent LC using the standard three-trocar technique during the same period. Both patient groups were comparable in age, gender, BMI and ASA classification., Results: The mean follow-up was 58.7 ± 10.9 (range 3-80) months. There were no differences between groups in terms of hospital stay, rate and severity of complications, wound infection, and patient cosmetic satisfaction. However, the operating time (57.8 versus 35.2 min) and long-term incisional hernia rate (13.3% versus 4.7%) were significantly higher in the SILC group., Conclusion: SILC is associated with a statistically significantly higher long-term incisional hernia rate at the umbilical port site than the standard multiport laparoscopic cholecystectomy. Our data show there was no relevant advantage regarding the postoperative course, hospital stay or cosmetic satisfaction. To date, widespread use of SILC cannot be recommended. Registration number: NCT03768661 (https://www.clinicaltrials.gov)., Trial Registration: This study has been registered at www.clinicaltrials.gov. The clinicaltrials.gov ID number is: NCT03768661.

Background: Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them., Methods: We reviewed 9402 cholecystectomies performed over 14 years by surgeons at the Hospital Nacional de San Benito (HNSB) in El Peten, Guatemala, with either an open or a laparoscopic approach. We conducted personal interviews with all the surgeons who perform cholecystectomies at HNSB to determine current practice and barriers to adopting LC., Results: Overall, seven general surgeons were interviewed who regularly perform cholecystectomy. Of the total number of cholecystectomies reviewed, 8440 (90%) were open and 962 (10%) were laparoscopic. The mean number of cholecystectomies performed per surgeon was 1341.1 ± 1244.9, with OC at 1205.7 ± 1194.9, and LC at 137.4 ± 188.0. Lack of formal training in laparoscopy was identified in 57% of surgeons. Lack of government funds to implement a laparoscopic program was noted by 71% of surgeons (29% felt there was insufficient ancillary staff, 29% poor allocation of hospital funding to purchase laparoscopic equipment/training). Lack of sufficient laparoscopic equipment was identified by 71% of surgeons., Conclusions: Ninety percent of cholecystectomies performed by surgeons at HNSB continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.

Bile duct injury represents a complication after laparoscopic cholecystectomy, impairing quality of life and resulting in subsequent litigations. A five-year experience of bile duct injury repairs in 52 patients at a community hospital was reviewed. Twenty-nine were female, and the median age was 51 years (range, 20-83 years). Strasberg classification identified injuries as Type A (23), B (1), C (1), D (5), E1 (5), E2 (6), E3 (4), E4 (6), and E5 (1). Resolution of the bile duct injury and clinical improvement represent main postoperative outcome measures in our study. The referral time for treatment was within 4 to 14 days of the injury. Type A injury was treated with endobiliary stent placement. The remaining patients required T-tube placement (5), hepaticojejunostomy (20), and primary anastomosis (4). Two patients experienced bile leak after hepaticojejunostomy and were treated and resolved with percutaneous transhepatic drainage. At a median follow-up of 36 months, two patients (Class E4) required percutaneous balloon dilation and endobiliary stent placement for anastomotic stricture. The success of biliary reconstruction after complicated laparoscopic cholecystectomy can be achieved by experienced biliary surgeons with a team approach in a community hospital setting.

Background: In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis., Methods: Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. One hundred ninety lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay (LOS), time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost., Results: Patients admitted to surgical (n = 106) versus medical (n = 84) service had shorter mean LOS (1.4 days vs. 2.6 days), shorter time from admission to surgery (0.4 days vs. 0.8 days), and shorter time from surgery to discharge (0.8 days vs. 1.1 days). Surgical service patients had fewer CT (38% vs. 56%) and magnetic resonance imaging (MRI) (5% vs. 16%) studies. Cholangiography (30% vs. 25%) and endoscopic retrograde cholangiopancreatography (ERCP) (3 vs. 8%) rates were similar. Surgical service patients had 39% lower median total costs (US $7787 vs. US $12572)., Conclusion: Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs., Level of Evidence: Therapeutic/care management, level IV.

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55-64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure ( P < 0.001). After adjustment, the probability of any GE increased with age category ( P < 0.001); having any GE was associated with higher probability of all outcomes ( P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose-response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.

Introduction: Few centers worldwide have advanced single-incision pediatric endosurgery (SIPES) for pediatric age group. Up to our knowledge this is the first study assessing the safety of SIPES cholecystectomy in children with sickle cell disease (SCD) done by surgical residents. Aims: To determine the feasibility, safety, and expediency of SIPES cholecystectomy in children with SCD performed by surgical residents. Materials and Methods: Retrospective study of all SIPES cholecystectomies performed in our unit from April 1, 2011 to March 31, 2018. We compared the outcome of SIPES cholecystectomy done by fellows and residents. SIPES Covidien 5-12 mm port was inserted through umbilicus. Long 50 cm laparoscope, straight regular instruments, and transabdominal gallbladder traction suture were used in all patients. The cystic duct and artery were identified and divided. The gallbladder is then dissected off the liver and extracted from the abdomen through the port. Results: Forty-three SCD patients underwent SIPES cholecystectomy for 7 years. Mean HbS was 37.56%. Mean age was 10 years. Twenty-four cases (56%) and 19 (44%) were performed by 8 fellows and 10 residents, respectively. Nine other procedures were done simultaneously with cholecystectomy and were excluded from the mean operative time (MOT). The MOT for all cases was 85 minutes, 78 minutes for fellows and 94 minutes for residents ( P value is <.001). One extra port was inserted in 2 patients at the beginning of the series. Conclusion: SIPES cholecystectomy in children with SCD is safe and feasible if done by residents under supervision. Stepwise training is essential in this challenging surgery. Involving residents with other SIPES procedures and hands-on minimally invasive surgery single port workshops help them in improving their skills.

Background: This prospective randomized study aims to compare outcomes between immediate laparoscopic cholecystectomy (LC) and same admission delayed LC in patients with acute cholecystitis and also to investigate the relation between oxidative stress markers and complication rates in the patients with AC., Methods: This study included 64 patients with AC who were randomly divided into two groups. Patients in Group 1 (n=32) were immediately administered LC, while in Group 2 (n=32) patients underwent transient LC following medical treatment. All patients were operated on their first hospitalization., Results: No statistically significant differences were observed between the groups for the comparison of complications, conversion rates, or operation durations (p>0.05). The length of postoperative hospital stay was found to be significantly shorter in group 1 compared to group 2 (1.75 vs 2.93 days; p=0.024). Only the total antioxidant status result was significantly higher in group 1 (p=0.017), but the finding was not correlated with complications., Conclusion: LC for AC was performed during the first admission was found to be safe, even beyond 72 hours following symptom onset. Pre-operative oxidative stress markers did not correlate with the complication rates.

Gallstones are one of the most common morbidities in the world. Laparoscopic cholecystectomy is the gold standard for gallbladder stones' removal. Few studies focus on the existence of predictive factors aimed at facilitating cholecystectomy in a day surgery setting. The aim of this retrospective study was to identify clinical factors that could guide day-surgery laparoscopic cholecystectomy safety. The study included 985 consecutive patients who underwent elective laparoscopic cholecystectomy for gallstone disease between May 2006 and February 2015. Patients were divided into two groups: group A with a length of stay ≤ 2 days (922 patients); group B with a length of stay > 2 days (63 patients). Univariate analysis showed that age, sex and the presence of obesity, cardiological, and nephrological comorbidities had a higher likelihood of a longer hospital stay. The logistic regression model showed that only age was a significant predictor of a longer stay. No complication has reached the statistical significance of extending the length of stay in group B. Conversely, the presence of such comorbidities has influenced the hospitalization. Our results allow the identification of a category of patients at high risk of hospitalization within 1 or 2 days from treatment. Moreover, we reported that there is no complication specifically affecting the length of stay. Our findings support the idea that a prolonged length of stay is not linked to the surgical procedure but to the patient's comorbidities.

Background: Laparoscopic cholecystectomy is the preferable treatment for chronic or acute cholecystitis. Some factors may increase the rate of laparoscopic conversion to open cholecystectomy and perioperative complications. The role of gender as a risk factor for laparoscopic cholecystectomy is controversial., Aim: To evaluate the role of the gender on the operative findings and outcome of laparoscopic cholecystectomy., Method: All patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis were included. Demographic, clinical, laboratory, imaging exams, intraoperative and postoperative data were obtained and analyzed. The data was obtained retrospectively from electronic medical records and study protocols., Results: Of a total 1,645 patients who were subjected to laparoscopic cholecystectomy, 540 (32.8%) were men and 1,105 (67.2%) were women. Mean age was similar in both genders (p=0.817). Operative time has longer in the male (72.48±28.50) than in the female group (65.46±24.83, p<0.001). The rate of acute cholecystitis was higher in the male (14.3%) than in the female group (5.1%, p<0.001). There was no difference between the genders in regard to the rate of conversion (p=1.0), intraoperative complication (p=1.0), postoperative complication (p=0.571), and operative mortality (p=1.0)., Conclusion: Male gender is not an independent risk factor for laparoscopic conversion and perioperative complications.

Background: The ideal mini-invasive management of common bile duct stones (CBDS) with concomitant gallbladder stones is debatable. This article aims to review the management of this condition during the last decade using the mini-invasive approach., Methods: A database research in Medline, Embase, Cochrane and Google Scholar during the period between January 2009 to December 2018 was performed. The keywords used were «ERCP», «common bile duct exploration», «endoscopic sphincterotomy», «laparoscopic surgery», «laparoscopic cholecystectomy», «choledocholithiasis», «common bile duct stones» «meta-analysis» and «randomized clinical trials»., Results: There were 14 studies comparing mini-invasive procedures. There were nine meta-analysis, three reviews articles and two randomized clinical trials. We concluded to the absence of difference between the group laparoscopic cholecystectomy (LC) with a laparoscopic exploration of CBD (LECBD) and LC with endoscopic retrograde cholangiopancreatography (ERCP) in terms of mortality, morbidity, stones extraction success rate and duration of hospital stay. LC + ERCP is superior in terms of conversion and treatment cost. Concerning LC with a preoperative ERCP versus LC with postoperative ERCP, based on the literature data, no conclusions could be drawn. Concerning LC with LECBD versus LC with preoperative ERCP, we conclude to the absence of difference in terms of mortality, morbidity and conversion rate. Given the discordance of the results, in terms of successful extraction rate of stones, operating time and duration of hospital stay we cannot conclude to the superiority of one technique. Concerning LC with LECBD versus LC with postoperative ERCP, we conclude the absence of difference in terms of mortality, morbidity, the success rate of stones extraction, duration of hospital stays and conversion rate. Concerning LC with intraoperative ERCP versus LC with preoperative ERCP, we concluded to the absence of difference in terms of mortality, morbidity and rate of success stones extraction. The LC + intraoperative ERCP was superior in terms of hospital stay duration and conversion rate. Concerning one-stage versus two-stage treatment, we concluded to the absence of difference in terms of mortality, morbidity, the success rate of stone extraction, the conversion rate and the duration of hospital stay., Conclusions: One-stage or two-stages procedures are feasible and safe with equivalent efficacy. Surgeons must be aware of the different difficulties of these procedures and should be judicious in their use of different techniques.

Background: Studies focused on C-reactive protein (CRP) as a marker of difficult laparoscopic cholecystectomy are limited to small case series. The aim of this study was to evaluate the association between preoperative CRP concentration and difficulty of laparoscopic cholecystectomy in patients admitted with a biliary emergency presentation., Methods: Patients with an emergency admission for biliary disease treated between 2012 and 2017 with a documented preoperative CRP level were analysed. Elective patients and those with other concurrent causes of increased CRP concentration were excluded. The intraoperative difficulty grade was based on the Nassar scale. Statistical analysis was conducted to determine the association of preoperative CRP level with difficulty grading, adjusted for the interval to surgery., Results: A total of 804 emergency patients were included. The mean preoperative peak CRP level was 64·7 mg/l for operative difficulty grade I, 69·6 mg/l for grade II, 98·2 mg/l for grade III, 217·5 mg/l for grade IV and 193·1 mg/l for grade V, indicating a significant association between CRP concentration and Nassar grade ( P  < 0·001). Receiver operating characteristic (ROC) curve analysis showed an area under the curve of 0·78 (95 per cent c.i. 0·75 to 0·82), differentiating patients with grade I-III from those with grade IV-V operative difficulty. ROC curve analysis found a cut-off CRP value of 90 mg/l, with 71·5 per cent sensitivity and 70·5 per cent specificity in predicting operative difficulty of grade IV or V. Logistic regression analysis found preoperative peak CRP level to be predictive of Nassar grade I-III versus grade IV-V operative difficulty, also when adjusted for timing of surgery (odds ratio 5·90, 95 per cent c.i. 2·80 to 12·50)., Conclusion: Raised preoperative CRP levels are associated with greater operative difficulty based on Nassar scale grading., (© 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

The operative experience of present-day surgical residency training has evolved as a result of the contributions of laparoscopic surgery. Some traditional open procedures are now more descriptive and less of a familiarity to many general surgery residents (GSRs). The aim of this study was to investigate how open operative experience compares with laparoscopy for GSRs. A retrospective, multicenter, consecutive cohort study of all patients undergoing surgical intervention involving the appendix and gallbladder identified from the ACS-NSQIP database over a 2.5-year period. All GSR postgraduate year-level operative experience was recorded. Of 777 procedures, 13 laparoscopic appendectomy conversions to open (4.3%) by Rocky-Davis (15%) or lower midline (84.6%) incisions were performed versus 285 that remained laparoscopic (95.6%). Fifty (10.4%) open cholecystectomies (38 open + 10 conversions + 2 common bile duct (CBD) exploration), 27 (5.6%) laparoscopic cholecystectomies with cholangiogram, and 402 (83.9%) laparoscopic cholecystectomies were performed. Twenty-nine different GSRs participated in procedures. Eighty-five (10.9%) operations were performed with multi-postgraduate year levels. Surgical residents have an unequal operative experience for case-specific open procedures. A competency-based system to demonstrate a resident's hands-on surgical skills is fundamental to residency training and should be considered for specific types of low-volume open surgical cases.

Objective: At present, cholecystectomy is carried out for thalassaemia patients with gall stone disease only if they develop symptoms of cholecystitis, except in the rare instance where an un-inflammed gall bladder is removed simultaneously with splenectomy. We carried out this retrospective analysis of case records to examine if patients with thalassaemia have a higher rate of peri operative complications compared to non-thalassaemics with gall stone disease, warranting a change of policy to justify elective cholecystectomy., Results: Case records of 540 patients with thalassaemia were retrospectively analysed of which 98 were found to have gallstones. Records of 62 patients without thalassaemia with gall stone disease too were used for comparison. 19 of patients with thalassaemia and 52 of non-thalassaemic who had gallstones had undergone cholecystectomy. In all but 5 patients with thalassaemia cholecystectomy was done following attacks of acute cholecystitis as was the case in the non-thalassaemic controls. A significantly higher proportion of early and late complications had occurred in thalassaemia patients compared to non-thalassaemic patients post operatively. Six deaths related to sepsis following acute cholecystitis in the peri operative period were reported among 19 thalassaemia patients whereas no deaths were reported among 55 non-thalassaemic patients who underwent cholecystectomy for gallstones.