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Adequate tissue oxygenation and perfusion remain fundamental to safe bowel resection surgery. Near infrared (NIR) imaging using indocyanine green has proven itself superior to clinical evaluation alone in assessing bowel perfusion, but requires expensive equipment not readily available in many centers. We studied the IntraOx device (Vioptix Inc, Newark, CA USA), a handheld, tissue oxygen saturation assessment tool, to assess whether tissue bed oxygen saturation (StO2) is comparable to NIR assessment of bowel viability. Patients undergoing elective colon resection for benign and malignant disease were included. After choosing a clinical margin (CM) and dividing the mesentery, StO2 was measured at 5-cm intervals along the colon. A tissue oxygen saturation margin (TOM) was assigned where StO2 dropped off by at least 10 percentage points. NIR perfusion was then assessed to determine NIR margin (NIRM). Intraoperative and postoperative data were collected. 32 consecutive patients undergoing colectomies were analyzed. IntraOx sensitivity was 90.6%, specificity was 94.3%. The mean StO2 difference across the NIRM was 23.1%. In all but one case, the TOM matched the NIRM. In 3 cases, the TOM and NIRM concurred, but were a mean of 3.3 cm proximal to the CM and altered the surgical plan. At 4-week follow-up, no significant complications were reported. The IntraOx device consistently identified a margin of significant saturation “drop-off” which correlated with the findings on NIR perfusion and clinical assessment. These early data indicate that StO2 measurement may be equivalent to NIR assessment of bowel perfusion. In addition, the IntraOx device may be a more cost-effective solution for surgeons looking for adjunctive evaluation of bowel viability. More study is warranted in a larger group of patients to confirm these preliminary findings and to judge the impact of StO2 assessment on reducing anastomotic leaks.

Background: In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed. Objective: In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety. Methods: A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8(th), 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively. Results: Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus. Conclusions: Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.

Every field of surgery has seen an explosion of new technologies aimed at improving surgical technique and reducing complications. The use of near-infrared (NIR) fluorescence to assess perfusion has been described in several surgical disciplines. NIR provides the surgeon with real-time perfusion assessment of a target organ or anastomosis and can be invaluable in aiding decision-making during the index operation. In the following article we discuss the use of fluorescence-guided perfusion assessment during colonic interposition for esophageal replacement. To our knowledge this is the first description of the use of fluorescence-guided perfusion assessment during colonic interposition.

The use of indocyanine green (ICG) fluorescence near-infrared (NIR) imaging during gastrointestinal surgery has surged in recent years. Its use in esophageal surgery is actively being studied both in the clinical setting and in the lab. NIR imaging has several important applications in esophageal surgery including assessing perfusion of the gastrointestinal-esophageal anastomosis, lymphatic drainage and tracheal blood flow after mediastinal dissection. This is a review of the modern literature summarizing the current knowledge on fluorescence-guided surgery of the esophagus.

HeartMate II left ventricular assist device (LVAD) assists heart failure patients by generating continuous flow via axial flow pump placed in the left ventricle. Little is known of the effect of continuous flow on intestinal anastomoses. This is the first case visually documenting altered perfusion patterns in patients with LVADs using indocyanine green (ICG). A 72-year-old male required a colon resection, for adenocarcinoma, following implantation of an LVAD. Perfusion of the anastomosis was evaluated using indocyanine. During the assessment, an unusual perfusion pattern was noticed. Normally, flow as measured by SPY is seen as an initial blush of contrast followed by a gradual, pulsatile increase in the progression of the indocyanine through the tissues. In this patient, instead of the usual initial blush, a continuous beam of ICG was seen to flow though the blood vessels. This novel perfusion pattern is consistent with flow generated from LVAD.

Peritoneopericardial diaphragmatic hernia is a rare entity involving herniation of abdominal viscera through the diaphragm into the pericardial sac. It is most often seen after blunt abdominal trauma, but can occur following any trans-diaphragmatic intervention. We report on a 56-year-old female with peritoneopericardial diaphragmatic hernia secondary to a convergent procedure for the treatment of atrial fibrillation, who underwent a laparoscopic repair. An anterior abdominal wall laparoscopic approach was employed. Transverse colon and greater omentum were within the hernia sac. The defect measuring 3 cm × 3 cm was repaired using a composite hernia mesh. The total operative time was 78 minutes. No intra-operative and no post-operative complications were observed. Patient remained asymptomatic at a 6-month follow-up. Laparoscopic mesh repair of peritoneopericardial diaphragmatic hernia is safe, feasible and is the procedure of choice for treating these complex hernias.

Adenomyomatous hyperplasia (AH) is commonly found in the gallbladder and is considered a tumor-like inflammatory lesion arising from Rokitansky-Aschoff sinus. It is extremely rare in the extrahepatic bile duct and only 15 cases have been reported to date. We describe a 63-year-old male patient who presented with cholangitis, underwent an extensive diagnostic workup, and ultimately had a Whipple procedure. Final pathology showed a 2.0 × 1.5 × 0.5 cm3 granular lesion in the distal common bile duct. There was prominent biliary epithelial proliferation with tubular–papillary architecture and minimal nuclear atypia in association with chronic inflammation, stroma reaction and smooth muscle proliferation. AH of the extrahepatic bile duct is a benign process but often requires a major operation to definitively diagnose.

Laparoscopic adjustable gastric band (LAGB) prolapse is a well-described complication following LAGB and is defined by the herniation of any portion of the gastric wall through the band in a proximal direction, with caudal migration of the band. Gastric band prolapse typically presents with some combination of food intolerance, nausea, vomiting, dysphagia, or worsening GERD. The mainstay of diagnosis is barium esophagography. Management of LAGB prolapse involves one of four options: a conservative non-operative approach, band removal, band revision (re-banding), and band removal with conversion to an alternate bariatric procedure. Limited and variable data preclude definitive recommendations regarding the optimal treatment, timing, and ideal revisional choice for these complex patients.

Transitioning from multiport laparoscopic totally extraperitoneal hernia repair to a single-incision technique can be readily accomplished without altering operative time or morbidity., Background: Laparoendoscopic single-site surgery (LESS) offers cosmetic benefits and may represent further progress towards reducing the invasiveness of surgical interventions. We report our initial experience with LESS totally extraperitoneal (TEP) inguinal herniorrhaphy. Materials and Methods: Beginning March 2009, we transitioned from a multiport laparoscopic TEP (MLH) technique to a single-incision TEP (SITE) technique. The first 52 consecutive patients who underwent SITE at our institution were compared with the preceding 52 MLH repairs. Results: Of the first 52 patients undergoing SITE, there were no conversions to either open or multiport surgery. The mean operative time for the SITE cases did not differ significantly from that of MLH. Complications were equivalent between the 2 groups and included postoperative seroma and urinary retention. Conclusions: Transitioning from MLH to SITE was readily accomplished without significantly altering operative time or morbidity.

The most challenging of the many hurdles surgeons must overcome to perform natural orifice translumenal endoscopic surgery (NOTES) safely is viscerotomy closure. The perfect device must be easy to deploy, suitable for use on any viscera, and able to create a rapid, reliable, and durable closure. The authors developed a novel device based on an existing circular stapler platform to create and then subsequently close a viscerotomy. The device was tested initially on an ex vivo porcine stomach model, then used on a survival canine model to confirm adequacy of gastric closure and rapidity of deployment.Three study arms, each containing five stomachs, were used. For the experimental arm, a Surgassist (PMI, Langhorne, PA, USA) powered circular stapler (EEA) modified with an auger tip and premounted endoloops was used. This novel device was compared with two gold standard closure techniques: hand-sewn two-layer closure and linear stapled closure. Each stomach then was inflated slowly with dye, and the pressure at which each closure leaked was recorded. For evaluation of the closure's durability and ease of use, five mongrel dogs undergoing transgastric intraabdominal surgery had their gastrotomy formed and closed using the modified Surgassist stapler. Each animal was survived 14 days, then killed, after which a necropsy was performed.In the ex vivo model, the modified PMI EEA consistently achieved burst pressures exceeding 260 mmHg, which was statistically significant compared with either the hand-sewn closure or the linear stapled closure. In the survival group, all the animals survived for the 2-week study period without signs of sepsis. At necropsy, the closures were found to be intact.The prototype transvisceral purse-string device consistently produced a tight, safe, and reliable closure. It can be deployed and cinch-closed rapidly. This study suggests that this new device may be a promising option for use in NOTES.

A standard approach for postoperative analgesia in laparoscopic surgery is to infiltrate the incisions with local anesthetic in combination with systemic opioids. The intraperitoneal introduction of local anesthetic in this setting has the potential to provide appropriate analgesia without the side effects of systemic opioids. We performed a randomized clinical trial of the On-Q pump delivery system to determine the safety and efficacy of this device for this novel purpose. Thirty patients undergoing laparoscopic adjustable gastric banding were randomly assigned to one of two groups. The treatment group received On-Q pump systems filled with 0.375% bupivacaine, while the control group received pumps filled with 0.9% normal saline. The pump’s catheter was introduced intraperitoneally, and bupivacaine or saline was then delivered for the first 48 h after surgery. Patient’s subjective pain scores were evaluated at preset intervals. In addition, shoulder pain, morphine requirements, and anti-emetic requirements were tabulated. A statistically significant decrease in patient’s subjective reports of pain by visual analog score was noted in the On-Q group 1.8 ± 1.93 vs. control 3.5 ± 2.4, p

Dear Editor, We read with interest the review article entitled ‘‘NearInfrared Fluorescence Imaging for Real-Time Intraoperative Anatomical Guidance in Minimally Invasive Surgery: A Systematic Review of the literature’’ by Schols et al. [1] Although we applaud the authors’ extensive literature review and thoughtful discussion, the authors incorrectly state that merged near-infrared (NIR) and whitelight (WL) image capabilities have not been incorporated into a laparoscopic or robotic platform. I respectfully refer them to a growing body of literature using the Pinpoint and Firefly systems (Novadaq Technologies, Mississauga, ON, Canada), both of which are designed specifically for merging NIR to WL images in laparoscopic and robotic surgery, respectively [2–4]. Merged WL and NIR imaging is the key to providing surgeons with truly augmented vision and the aforementioned commercially available systems very effectively allow for real-time minimally invasive surgery with a seamlessly superimposed fluorescence overlay.

The Pinpoint system, an endoscopic real-time fluorescence imaging system, incorporates both a high definition (HD) white light and near infra-red (NIR) fluorescence excitation and acquisition systems into a single camera head. The standard white light view and NIR are thus retained throughout the procedure enabling the surgeon to operate with real-time fluorescence guidance. Our group has concentrated on the use of Pinpoint in the assessment of colorectal perfusion and intraoperative cholangiography. In addition, we describe our early experience using Pinpoint for sentinel lymph node dissection in colorectal and gastric malignancies and discuss future applications of this technology.

Background: The most prevalent long-term complications in patients who undergo laparoscopic adjustable gastric band (LAGB) surgery are pouch dilatation and gastric prolapse (slippage). Gastric prolapse can be divided into the anterior and posterior variety. Posterior prolapse is thought to be specific to the perigastric approach due to a lack of posterior band fixation. We report a series of 3 patients out of 1,104 who underwent LAGB placement using the pars flaccida approach and developed a posterior prolapse. Methods: Between March 2002 and December 2005, 1,104 patients underwent LAGB insertion using the pars flaccida approach at our institution. 3 patients (0.27%) developed posterior prolapse requiring reoperation. Results: All 3 patients presented with similar complaints, including solid food intolerance, gastroesophageal reflux and/or regurgitation. Although identical to those reported with anterior prolapse, diagnosis was definitively made with barium video esophagogram. All patients were treated with reoperation, but band replacement was impossible in 2 of the 3 cases secondary to extensive adhesion formation. Conclusion: The finding of 3 patients who experienced posterior prolapse, despite using the pars flaccida approach, highlights the fact that this complication although diminished, has not been eliminated as previously thought. We describe the presentation, work-up, and management of this rare but important entity in the modern era of LAGB.

The rigid sigmoidoscope is an important tool in a surgeon’s armamentarium, yet it has remained essentially unchanged despite poor imaging and the inability to project or record the images. Herein we report our initial experience with a novel introducer built from readily available operating room supplies and designed to convert any standard laparoscope into a high-definition rigid sigmoidoscope.

These authors conclude that laparoscopic distal pancreatectomy can be safely and effectively performed by surgeons skilled in basic laparoscopy and does not require specialized training or to be performed in a specialized center., Background: Laparoscopic management of distal pancreatic malignancies has been slow to gain a foothold in all but high-volume tertiary referral centers. The aim of this study was to assess the safety and outcomes of laparoscopic distal pancreatectomy (LDP) performed in a low-volume community hospital by a diverse group of surgeons, none of whom have a specialized laparoscopic background. Methods: We conducted a retrospective review of all patients who underwent open distal pancreatectomies (ODPs) and LDPs between August 2001 and June 2008. Data included type of surgery, open versus laparoscopy, demographics, operative time, blood loss, length of hospital stay, histopathologic diagnosis, postoperative complications, American Society of Anesthesiologists score, and mortality. Results: Twenty-seven patients with pancreatic masses underwent distal pancreatic resection during the study period. Fifty-nine percent (n = 16) underwent LDP, and 41% (n = 11) underwent ODP. Mean patient age was 66 y (range, 40 to 86) for the LDP group and 62 (range, 40 to 84) for the ODP group. Mean operative time was 231 min (range, 195 to 305) for LDP and 240 (range, 150 to 210) for the ODP technique. Mean length of stay for LDP and ODP was 8 (range, 3 to 22) and 12 d (range, 5 to 2), respectively. Morbidity was 25% (n = 4) in the LDP group and 36% (n = 4) in the ODP group. None of the differences between the LDP and ODP groups were statistically significant. No mortalities occurred in either group. Conclusion: This study supports the idea that LDP can be safely and effectively performed by any surgeon comfortable with basic laparoscopy and may not require specialized training or a specialized center. Further data are required to make more definitive conclusions.

Background: Intraoperative cholangiography facilitates identification of biliary anatomy and may help prevent main duct injury during laparoscopic cholecystectomy. Despite this potential benefit, the added operative time and the need to inject contrast directly into the biliary system have prevented it from becoming routine.1–3 Fluorescent cholangiography using an intravenous fluorophore and near-infrared (NIR) imaging provides similar anatomical detail without the drawbacks of radiographic cholangiography. Methods: The Pinpoint system (Novadaq, Canada) is a laparoscopic NIR imaging system that takes advantage of the biochemical and fluorescent properties of indocyanine green (ICG). After being injected intravenously, ICG is rapidly taken up by the liver and excreted in the bile. ICG fluoresces at a peak wavelength of ∼830 nm when exposed to NIR light and can then be visualized in the biliary tree. The pinpoint was used in 19 cases as a part of a randomized controlled study. In all cases, 1 mL (2...

The influence of perfusion on colorectal anastomotic healing and, conversely, the role of ischemia in anastomotic dehiscence have been reported by many investigators, and yet identifying a modality that can evaluate perfusion in real time and thus guide intraoperative management has proven elusive. This study describes our initial experience using transanal near-infrared (NIR) imaging to evaluate anastomotic perfusion after colorectal anastomoses. Patients undergoing colectomy with an anastomosis within 25 cm of the anal verge were included in this study. A transanal NIR system was used to assess mucosal perfusion at the level of the anastomoses. The rectum was easily navigated under direct vision and the anastomotic staple line visualized. High-quality NIR mucosal angiography was obtained in all subjects, confirming that transanal NIR angiography is feasible and simple to perform. Although NIR mucosal angiography is a promising modality, further study is needed to correlate this technique to the clinical outcome.

Single-incision laparoscopic cholecystectomy (SILC) promises improved cosmesis and may further minimize the invasiveness of intraabdominal interventions but cannot come at the expense of patient safety. This study describes the evaluation of a novel 5-mm instrument designed for SILC that maintains an equivalent critical view to that obtained with standard multiport laparoscopic cholecystectomy (MLC).Sixteen animals were randomly assigned to one of four study arms. Four techniques for laparoscopic cholecystectomy were used: standard four-port MLC, three-instrument SILC (SILC-A), three-instrument SILC using a suture for lateral retraction (SILC-B), and three-instrument SILC using the novel instrument for retraction (SILC-C). Each case was timed and video-recorded. The video was cropped to obscure the method of retraction and evaluated by five experienced laparoscopic surgeons blinded to the technique used. Each case was rated subjectively on a safety and visualization scale of 1-4.SILC-A and SILC-B cases were significantly longer in duration than both SILC-C and MLC cases. The safety and visualization scale results were lower for the SILC-A technique but were equivalent for the MLC, SILC-B, and SILC-C techniques.This study introduces a novel instrument for gallbladder retraction. In this initial evaluation, the new instrument showed encouraging results in its ability to generate good visualization, support the safe critical view technique, and reduce the length of the procedure.

With over 20 million repairs performed worldwide annually, inguinal hernias represent a significant source of disability and loss of productivity. Natural orifice translumenal endoscopic surgery (NOTES™), as a potentially less invasive form of surgery may reduce postoperative disability and accelerate return to work. The objective of this study was to assess the safety and short-term effectiveness of transgastric inguinal herniorrhaphy using a biologic mesh in a survival canine model.Under general anesthesia with the animal in Trendelenburg position, a gastrostomy was created. A 4 × 6 cm acellular dermal implant was deployed endoscopically across the myopectineal orifice, draped over the cord structures, and secured with Bioglue. Following completion of bilateral repairs the animals were survived for 14 days. At the end of the study period, the animals were euthanized and a necropsy performed. Cultures of a random site within the peritoneal cavity and at the site of implant deployment were obtained. In addition, a visual inspection of the peritoneal cavity was performed.All animals thrived postoperatively and did not manifest signs of peritonitis or sepsis at any point. At necropsy accurate placement and adequate myopectineal coverage was confirmed in all subjects. Cultures of a random site within the peritoneal cavity and at the site of implant deployment had no growth.This study confirms that NOTES-inguinal herniorrhaphy using a biologic implant can be performed safely. In addition, the transgastric technique provided good short-term myopectineal coverage without infectious sequelae.

Background The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse. Methods The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm 3 was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus. Results Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve. Conclusion The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.

Background A potentially less-invasive technique, transluminal surgery, may reduce or eliminate pain and decrease time to full return of activities after abdominal operations. Inguinal hernia repair is perfectly suited to the transgastric endoscopic approach and has not been previously reported. Objective Our purpose was to evaluate the feasibility of transgastric bilateral inguinal herniorrhaphy (BIH). Design Feasibility study with a nonsurvival canine model. Interventions Under general anesthesia, male mongrel dogs weighing 20 to 30 kg had a dual-channel endoscope introduced into the peritoneal cavity over a percutaneously placed guidewire. An overtube with an insufflation channel was used. Peritoneoscopy was performed, and bilateral deep and superficial inguinal rings were identified. The endoscope was removed, premounted with a 4 × 6 cm acellular human dermal implant and then readvanced intraperitoneally through the overtube. The implant was then deployed across the entire myopectineal orifice and draped over the cord structures. Bioglue was then applied endoscopically, and the implant was attached to the peritoneum. After completion of bilateral repairs, the animals were killed and necropsy performed. Results Five dogs underwent pure natural orifice transluminal endoscopic surgery (NOTES) intraperitoneal onlay mesh (IPOM) BIH. Accurate placement and adequate myopectineal coverage was accomplished in all subjects. At necropsy no injuries to the major structures were noted but Bioglue misapplication with contamination of unintended sites did occur. Limitations Our study involved only a small number of subjects in nonsurvival experiments, and no gastric closure was used. Conclusions Many of the characteristics of inguinal hernia repair are especially well suited to the transgastric approach. The repair is in line with the transgastric endoscope vector, bilateral defects are adjacent, and the IPOM technique does not require significant manipulation or novel instrumentation.

The laparoscopic adjustable gastric band (LAGB) has proven itself a procedure with excellent long-term weight loss results and extremely low morbidity and mortality. The LAGB has become an indispensable addition to the armamentarium of most bariatric surgeons. Commonly reported complications associated with the lap band system include gastric prolapse, band erosion, hardware infection, and port/tubing leakage.We report a case of a patient suspected of having a Lap-Band leak. He presented with a clinical course of multiple adjustments without restriction and inability to aspirate the expected volume from the band. Following adjustment under fluoroscopy he became severely dysphagic. He underwent urgent operative exploration and was found to have an intact but overinflated band. Under close inspection, a clot in the proximal band was noted, acting as a ball valve allowing the addition of fluid but not aspiration.This case highlights an unusual explanation for what is thought of as typical signs of band leakage. In addition it raises serious questions about the importance of preventing blood and particulate matter from entering the Lap-Band system both at the initial operation and at subsequent adjustments.

Intraoperative cholangiography (IOC) is especially helpful for the detection of anomalous biliary anatomy during laparoscopic cholecystectomy. Fluorescent cholangiography using an intravenously injected fluorophore and near-infrared (NIR) imaging provides similar anatomical detail to standard radiographic cholangiography without ionizing radiation, puncture of the biliary system, or additional operative time. This video shows a laparoscopic cholecystectomy performed under NIR cholangiographic guidance and highlights its ability to identify anomalous anatomy.The attached video shows a laparoscopic cholecystectomy being performed on a 28-year-old female with a history of biliary colic and ultrasonographic evidence of cholelithiasis. This patient agreed to be part of a larger randomized study looking at near-infrared cholangiography and its ability to prevent common bile duct injuries (approved by the ethics review board of our institution and registered with clinicaltrials.gov Identifier# NCT01424215). This study uses the Pinpoint system (Novadaq, Ontario, Canada) for NIR imaging (Fig. 1). The Pinpoint mates a high definition white light laparoscopic view to the NIR cholangiography, providing an uninterrupted, augmented view of the anatomy. 1 cm(3) of indocyanine green was injected intravenously prior to the procedure.As shown in the video, an anomalous duct was identified during dissection and development of the critical view of safety. Because of the possibility that this represented an aberrant right hepatic duct, the cystic duct was controlled and divided distal to the anomalous duct and the gall bladder excised from the fossa in the usual manner. The patient did well without sequelae at 1 week and 1 month follow-up.Anomolous ductal anatomy of the biliary tree has been reported in up to 23 % of cases.1,2 The ability of IOC to elucidate biliary anatomy and thus prevent bile duct injury has led many to espouse routine cholangiography for all laparoscopic cholecystectomies.3,4 Near-infrared cholangiography (NIRC) is easy to perform, does not add steps to the operative procedure, and produces a similar anatomic roadmap of the hepatocystic triangle to that of standard IOC. Although the clinical significance of the anomalous duct identified in this video is unknown, this video highlights the excellent detail provided by NIRC. Recommendations regarding the routine use of this new technology await the results of an ongoing randomized control study.

Dear Editor, We read with interest the letter written by La Colla and colleagues and appreciate their comments. We agree that sample size calculations are integral to evaluating the results of studies that contain non-significant results [1, 2]. Yet, where statistical significance is found, such as for the visual analog scale in our paper, the null hypothesis has already been rejected, and thus, a calculation of sample size is superfluous. Furthermore, we are surprised that La Colla and colleagues assume that all biostatisticians believe in the importance of post hoc power calculations. This is a matter of debate, with many disagreeing about the usefulness and importance of post hoc power calculations [3, 4]. We therefore maintain that our conclusions regarding the positive effects of continuous infusion intraperitoneal bupivacaine on post-bariatric subjective pain scores remain valid.