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Del Fabbro D, Procopio F, Galvanin J, Costa G, Famularo S, Palmisano A, Donadon M, Torzilli G. Intraoperative cholangio-ultrasonography (IOCUS) during hepatectomy with resection of the biliary confluence: An effective alternative to intraoperative cholangiography. Hepatobiliary Pancreat Dis Int 2024; 23:417-420. [PMID: 37516588 DOI: 10.1016/j.hbpd.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 07/18/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Daniele Del Fabbro
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy
| | - Fabio Procopio
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele 20072, Milan, Italy
| | - Jacopo Galvanin
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy
| | - Guido Costa
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy
| | - Simone Famularo
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy
| | - Angela Palmisano
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy
| | - Matteo Donadon
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele 20072, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, Rozzano 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele 20072, Milan, Italy.
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Hwang F, Bukur M. Contemporary management of common bile duct stone: What you need to know. J Trauma Acute Care Surg 2023; 95:832-838. [PMID: 37697464 DOI: 10.1097/ta.0000000000004128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Choledocholithiasis is a common presentation of symptomatic cholelithiasis encountered by the acute care surgeon. There is a wide spectrum of variation in management of this disease due to evolutions in laparoscopic and endoscopic techniques. Intricacies in management are related to the timing of diagnosis as well as locally available imaging modalities, surgical expertise, and ancillary advanced endoscopy and interventional radiological support. While individual patient demographics and institutional characteristics will determine management of choledocholithiasis, it is incumbent for the treating surgeon to be well versed in all manners of therapy currently available. The objective of this review is to provide an evidence-based summary of the contemporary management of choledocholithiasis.
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Affiliation(s)
- Franchesca Hwang
- From the Department of Surgery (F.H.), NYU Langone Health, Brooklyn, New York; and Department of Surgery (M.B.), Bellevue Hospital Center, New York, New York
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Awan B, Elsaigh M, Marzouk M, Sohail A, Elkomos BE, Asqalan A, Baqar SO, Elgndy N, Saleh O, Szul J, San Juan A, Alasmar M. A Systematic Review of Laparoscopic Ultrasonography During Laparoscopic Cholecystectomy. Cureus 2023; 15:e51192. [PMID: 38283459 PMCID: PMC10817818 DOI: 10.7759/cureus.51192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
We aim to investigate the potential of laparoscopic ultrasonography (LUS) as a replacement for intraoperative cholangiography (IOC) in the context of laparoscopic cholecystectomy focusing on various aspects related to both techniques. We made our search through PubMed, Web of Science, Cochrane Library, and Scopus, with the use of the following search strategy: ("laparoscopic ultrasonography" OR LUS OR "laparoscopic US" OR "laparoscopic ultrasound") AND ("laparoscopic cholecystectomy" OR LC). We incorporated diverse studies that addressed our topic, offering data on the identification of biliary anatomy and variations, the utilization of laparoscopic ultrasound in cholecystitis, the detection of common bile duct stones, and the criteria utilized to assess the accuracy of LUS. A total of 1526 articles were screened and only 20 were finally included. This systematic review assessed LUS and IOC techniques in cholecystectomy. IOC showed higher failure rates due to common duct catheterization challenges, while LUS had lower failure rates, often linked to factors like steatosis. Cost-effectiveness comparisons favored LUS over IOC, potentially saving patients money. LUS procedures were quicker due to real-time imaging, while IOC required more time and personnel. Bile duct injuries were discussed, highlighting LUS limitations in atypical anatomies. LUS aided in diagnosing crucial conditions, emphasizing its relevance post surgery. Surgeon experience significantly impacted outcomes, regardless of the technique. A previous study discussed that LUS's learning curve was steeper than IOC's, with proficient LUS users adjusting practices and using IOC selectively. Highlighting LUS's benefits and limitations in cholecystectomy, we stress its value in complex anatomical situations. LUS confirms no common bile duct stones, avoiding cannulation. LUS and IOC equally detect common bile duct stones and visualize the biliary tree. LUS offers safety, speed, cost-effectiveness, and unlimited use. Despite the associated expenses and learning curve, the enduring benefits of using advanced probes in LUS imaging suggest that it could surpass traditional IOC. The validation of this potential advancement relies heavily on incorporating modern probe studies. Our study could contribute to the medical literature by evaluating their clinical validity, safety, cost-effectiveness, learning curve, patient outcomes, technological advancements, and potential impact on guidelines and recommendations for clinical professionals.
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Affiliation(s)
- Bakhtawar Awan
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Mohamed Elsaigh
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Mohamed Marzouk
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Azka Sohail
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | | | - Ahmad Asqalan
- Thoracic Surgery, Norfolk and Norwich University Hospital, Norwich, GBR
| | - Safa O Baqar
- Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth, Plymouth, GBR
| | - Noha Elgndy
- Acute and Emergency Medicine, Frimley Park Hospital, Surrey, GBR
| | - Omnia Saleh
- General and Gastrointestinal Surgery, Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Justyna Szul
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Anna San Juan
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Mohamed Alasmar
- General Surgery, Salford Royal Hospital, University of Manchester, Manchester, GBR
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Temperley HC, O'Sullivan NJ, Grainger R, Bolger JC. Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy? Surgeon 2023; 21:e242-e248. [PMID: 36710125 DOI: 10.1016/j.surge.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/20/2022] [Accepted: 01/08/2023] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy. METHODS A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against. RESULTS From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC. CONCLUSIONS In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.
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Affiliation(s)
| | | | - Richard Grainger
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Jarlath C Bolger
- Department of Surgery, Toronto General Hospital/University Health Network, Toronto, ON, Canada; Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Laparoscopic Ultrasound for Bile Duct Imaging during Cholecystectomy: Clinical Impact in 785 Consecutive Cases. J Am Coll Surg 2022; 234:849-860. [DOI: 10.1097/xcs.0000000000000111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Cirocchi R, Panata L, Griffiths EA, Tebala GD, Lancia M, Fedeli P, Lauro A, Anania G, Avenia S, Di Saverio S, Burini G, De Sol A, Verdelli AM. Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements. J Clin Med 2021; 10:5238. [PMID: 34830520 PMCID: PMC8622805 DOI: 10.3390/jcm10225238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. METHODS We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. RESULTS The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a "poor" visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. CONCLUSIONS During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Laura Panata
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
| | - Ewen A. Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham B15 2GW, UK;
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Giovanni D. Tebala
- Surgical Emergency Unit, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Massimo Lancia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Piergiorgio Fedeli
- School of Law, Legal Medicine, University of Camerino, 62032 Camerino, Italy;
| | - Augusto Lauro
- Department of Surgical Sciences, Hospital “Policlinico Umberto I”, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Gabriele Anania
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy;
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Salomone Di Saverio
- Department of General Surgery, ASUR Marche, AV5, Hospital of San Benedetto del Tronto, 63074 San Benedetto del Tronto, Italy;
| | - Gloria Burini
- Department of General and Emergency Surgery, Hospital “Ospedali Riuniti di Ancona”, 60126 Ancona, Italy
| | - Angelo De Sol
- Department of General Surgery, St. Maria Hospital, 05100 Terni, Italy;
| | - Anna Maria Verdelli
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
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Pesce A, Piccolo G, Lecchi F, Fabbri N, Diana M, Feo CV. Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application. World J Gastroenterol 2021; 27:5989-6003. [PMID: 34629815 PMCID: PMC8476339 DOI: 10.3748/wjg.v27.i36.5989] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/10/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic cholecystectomy (LC) is one of the most frequently performed gastrointestinal surgeries worldwide. Bile duct injury (BDI) represents the most serious complication of LC, with an incidence of 0.3%-0.7%, resulting in significant perioperative morbidity and mortality, impaired quality of life, and high rates of subsequent medico-legal litigation. In most cases, the primary cause of BDI is the misinterpretation of biliary anatomy, leading to unexpected biliary lesions. Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings. The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.
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Affiliation(s)
- Antonio Pesce
- Department of Surgery, Section of General Surgery, Ospedale del Delta, Azienda USL of Ferrara, University of Ferrara, Ferrara 44023, Italy
| | - Gaetano Piccolo
- Department of Health Sciences, University of Milan, Unit of Hepato-Bilio-Pancreatic and Digestive Surgery, San Paolo Hospital, Milano 20142, Italy
| | - Francesca Lecchi
- Department of Health Sciences, University of Milan, Unit of Hepato-Bilio-Pancreatic and Digestive Surgery, San Paolo Hospital, Milano 20142, Italy
| | - Nicolò Fabbri
- Department of Surgery, Section of General Surgery, Ospedale del Delta, Azienda USL of Ferrara, University of Ferrara, Ferrara 44023, Italy
| | - Michele Diana
- Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, IRCAD, Research Institute Against Digestive Cancer, ICUBE lab, PHOTONICS for Health, University of Strasbourg, Strasbourg Cedex F-67091, France
| | - Carlo Vittorio Feo
- Department of Surgery, Section of General Surgery, Ospedale del Delta, Azienda USL of Ferrara, University of Ferrara, Ferrara 44023, Italy
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Cho YJ, Nam SH, Oh E, Luciano MP, Lee C, Shin IH, Schnermann MJ, Cha J, Kim KW. Laparoscopic cholecystectomy in a swine model using a novel near-infrared fluorescent IV dye (BL-760). Lasers Surg Med 2021; 54:305-310. [PMID: 34490931 DOI: 10.1002/lsm.23470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Bile duct injury during laparoscopic cholecystectomy has an incidence rate of 1%-2% and commonly appears under conditions of severe inflammation, adhesion, or unexpected anatomical variations. Despite the difficulties and rising concerns of identifying bile duct during surgeries, surgeons do not have a specific modality to identify bile duct except intraoperative cholangiography. While no biliary-specific fluorescent dye exists for clinical use, our team has previously described the development of a preclinical biliary-specific dye, BL-760. Here, we present our study of laparoscopic cholecystectomy using the fluorescent dye in a swine model. STUDY DESIGN/MATERIALS AND METHODS With an approval from Institutional Animal Care and Use Committee, two 20-25 kg swine underwent laparoscopic abdominal surgery using a Food and Drug Administration-cleared fluorescent laparoscopic system. Images of the liver and gallbladder were taken both before and after intravenous injection of the novel fluorescent dye. The dye was dosed at 60 μg/kg and injected via the ear vein. The amount of time taken to visualize fluorescence in the biliary tract was measured. Fluorescent signal was observed after injection, and target-to-background ratio (TBR) of the biliary tract to surrounding cystic artery and liver parenchyma was measured. RESULTS Biliary tract visualization under fluorescent laparoscopy was achieved within 5 min after the dye injection without any adverse effects. Cystic duct and extrahepatic duct were clearly visualized and identified with TBR values of 2.19 and 2.32, respectively, whereas no fluorescent signal was detected in liver. Cystic duct and artery were successfully ligated by an endoscopic clip applier with the visual assistance of highlighted biliary tract images. Laparoscopic cholecystectomy was completed within 30 min in each case without any complications. CONCLUSIONS BL-760 is a novel preclinical fluorescent dye useful for intraoperative identification and visualization of biliary tract. Such fluorescent dye that is exclusively metabolized by liver and rapidly excreted into biliary tract would be beneficial for all types of hepato-biliary surgeries. With the validation of additional preclinical data, this novel dye has potential to be a valuable tool to prevent any iatrogenic biliary injuries and/or bile leaks during laparoscopic abdominal and liver surgeries.
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Affiliation(s)
- Yu Jeong Cho
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, District of Columbia, USA.,Department of Surgery, Asan Medical Center, Songpa-Gu, Seoul, South Korea
| | - So-Hyun Nam
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, District of Columbia, USA.,Department of Surgery, Dong-A University College of Medicine, Seo-Gu, Busan, South Korea
| | - Eugene Oh
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, District of Columbia, USA.,Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael P Luciano
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Maryland, USA
| | - Choonghee Lee
- InTheSmart Co., Center for Medical Innovation Bld., Jongro-gu, Seoul, South Korea
| | - Il Hyung Shin
- InTheSmart Co., Center for Medical Innovation Bld., Jongro-gu, Seoul, South Korea
| | - Martin J Schnermann
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Maryland, USA
| | - Jaepyeong Cha
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, District of Columbia, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Kwan Woo Kim
- Department of Surgery, Dong-A University College of Medicine, Seo-Gu, Busan, South Korea
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Bansal VK, Misra MC, Agarwal AK, Agrawal JB, Agarwal PN, Aggarwal S, Aslam M, Krishna A, Baksi A, Behari A, Bhattacharjee HK, Bhojwani R, Chander J, Chattopadhyay TK, Chintamani, Chowbey P, Dalvi A, Dash NR, Dhawan IK, Gamangatti S, Garg PK, Gupta NM, Gupta R, Gupta SK, Gupta V, Kaman L, Kapur BML, Kataria K, Khan M, Khanna AK, Khullar R, Kumar A, Kumar A, Kumar S, Kumar S, Lal P, Maurya SD, Moirangthem GS, Pal S, Panwar R, Parshad R, Pottakkat B, Prajapati OP, Puntambekar S, Ranjan P, Rathore YS, Sahni P, Sarangi R, Seenu V, Sharma R, Shukla VK, Singh DP, Singh J, Singh R, Sinha R, Sikora SS, Srivastava A, Srivastava A, Srivastava KN, Thomas S, Verma GR, Wig JD, Kapoor VK. SELSI Consensus Statement for Safe Cholecystectomy — Prevention and Management of Bile Duct Injury — Part A. Indian J Surg 2021; 83:592-610. [DOI: 10.1007/s12262-019-01993-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/08/2019] [Indexed: 02/07/2023] Open
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Gandhi JA, Shinde PH, Chaudhari SN, Banker AM. Novel Use of Intraoperative Fluoroscopy in an Era of ICG for Complex Laparoscopic Cholecystectomy. Surg J (N Y) 2021; 7:e35-e40. [PMID: 33659641 PMCID: PMC7917001 DOI: 10.1055/s-0040-1721432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/14/2020] [Indexed: 12/07/2022] Open
Abstract
Background
Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD.
Methods
A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct.
Results
The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment.
Conclusion
This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.
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Affiliation(s)
- Jignesh A Gandhi
- Department of GI and Laparoscopic Surgery, Global Hospital, Mumbai, Maharashtra, India
| | - Pravin H Shinde
- Department of General Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Sadashiv N Chaudhari
- Department of General Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Amay M Banker
- Department of General Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Donnellan E, Coulter J, Mathew C, Choynowski M, Flanagan L, Bucholc M, Johnston A, Sugrue M. A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy? Surg Open Sci 2021; 3:8-15. [PMID: 33937738 PMCID: PMC8076912 DOI: 10.1016/j.sopen.2020.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete. METHODS An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. RESULTS Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23). CONCLUSION The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.
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Affiliation(s)
- Eoin Donnellan
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Jonathan Coulter
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Cherian Mathew
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Michelle Choynowski
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Louise Flanagan
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Londonderry, Northern Ireland
| | - Alison Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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12
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Liu Y, Peng Y, Su S, Fang C, Qin S, Wang X, Xia X, Li B, He P. A meta-analysis of indocyanine green fluorescence image-guided laparoscopic cholecystectomy for benign gallbladder disease. Photodiagnosis Photodyn Ther 2020; 32:101948. [PMID: 32771612 DOI: 10.1016/j.pdpdt.2020.101948] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/27/2020] [Accepted: 07/31/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND This meta-analysis was conducted to evaluate the effectiveness and safety of indocyanine green fluorescence image-guided laparoscopic cholecystectomy for benign gallbladder disease. METHODS Clinical studies were retrieved from PubMed, Embase, Cochrane Library, Medline, and the Web of Science databases. Study-specific effect sizes and their 95 % confidence intervals (CIs) were combined to calculate the pooled values, using fixed-effects or random-effects models. RESULTS Eleven studies with combined total of 2221 patients were included. Compared to the control group, the indocyanine green fluorescence imaging-guided group experienced shorter operative time (standardized mean difference [SMD] = -0.30; 95 % CI = -0.45 - -0.15; P < 0.001), shorter biliary anatomy identification time (SMD = -2.34; 95 % CI = -2.58 - -2.10; P < 0.001), lower blood loss (SMD = -0.14; 95 % CI = -0.26 - -0.01; P = 0.035), higher success rate of biliary tract imaging (odds ratio [OR] = 2.37; 95 % CI = 1.09-5.12; P = 0.029), lower rate of conversion to open surgery (OR = 0.10; 95 % CI = 0.04 - 0.28; P < 0.001), shorter hospital stay (SMD = -0.23; 95 % CI = -0.39 - -0.06, P = 0.008), and lower biliary tract imaging costs (SMD = -247.88; 95 % CI, -274.31--221.45, P = 0.000). Postoperative complications did not differ between the groups. CONCLUSION This systematic review shows that indocyanine green fluorescence biliary tract imaging is a safe and feasible new way for biliary tract identification in laparoscopic cholecystectomy.
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Affiliation(s)
- Yu Liu
- Department of Hepatobiliary Surgery, People's Hospital of Leshan, Sichuan, Leshan, 614000, China
| | - Yisheng Peng
- Department of General Surgery(Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Song Su
- Department of General Surgery(Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Cheng Fang
- Department of General Surgery(Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China
| | - Shu Qin
- Department of General Surgery(Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China; Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, 646000, China
| | - Xuewen Wang
- Department of Hepatobiliary Surgery, Zigong Fourth People's Hospital, Zigong 643000, China
| | - Xianming Xia
- Department of General Surgery(Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China; Academician(Expert)Workstation of Sichuan Province, Luzhou, 646000, China
| | - Bo Li
- Department of General Surgery(Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China; Academician(Expert)Workstation of Sichuan Province, Luzhou, 646000, China.
| | - Pan He
- Department of General Surgery(Hepatobiliary Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, China; Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, 646000, China; Academician(Expert)Workstation of Sichuan Province, Luzhou, 646000, China.
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Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Ann Surg 2020; 272:3-23. [PMID: 32404658 DOI: 10.1097/sla.0000000000003791] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. METHODS Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. RESULTS Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. CONCLUSIONS These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
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Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy. Surg Endosc 2020; 34:2827-2855. [PMID: 32399938 DOI: 10.1007/s00464-020-07568-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. METHODS Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. RESULTS Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. CONCLUSION These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
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Recommendation for cholecystectomy protocol based on intraoperative ultrasound - a single-centre retrospective case-control study. Wideochir Inne Tech Maloinwazyjne 2020; 16:54-61. [PMID: 33786117 PMCID: PMC7991927 DOI: 10.5114/wiitm.2020.93999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/24/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction There is a strong need to make laparoscopic cholecystectomy as safe as possible, but sometimes complications in the form of bile duct and/or vascular injury occur. The safe plane of dissection can be precisely identified with intraoperative ultrasound, ensuring reduction of the complication rate to a minimum. Aim To evaluate the advantages of the cholecystectomy protocol based on the use of intraoperative ultrasound during laparoscopic and open cholecystectomy. Material and methods The study group consisted of 700 patients with symptomatic cholecystolithiasis, which was divided into two subgroups: with the critical view of safety only (312 patients) and with the critical view of safety + laparoscopic/open cholecystectomy ultrasound (388 patients). Laparoscopic cholecystectomy and conversion in patients from the second subgroup were performed under the control of intraoperative ultrasound. Results We did not observe any biliary complications, and the visualization of the common bile duct, the proper hepatic artery and the portal vein was obtained in every patient from the critical view of safety + laparoscopic/open cholecystectomy ultrasound group. The mean time of the operation was significantly shorter and the conversion, biliary injury and intraoperative bleeding rates were significantly lower in this group of patients. Conclusions Intraoperative ultrasound is a very efficient and safe method of guidance, and its use should be standard along with the critical view of safety during cholecystectomy.
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Affiliation(s)
- Maria S Altieri
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 Euclid Avenue, Campus Box 8109, St Louis, MO 63110, USA
| | - L Michael Brunt
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 Euclid Avenue, Campus Box 8109, St Louis, MO 63110, USA.
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Abstract
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
| | - Gaurav Jain
- Transplant and HPB Surgery, the Iowa Clinic-Iowa Methodist Hospital, Des Moines, IA 50309, United States
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Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg 2019; 11:62-84. [PMID: 30842813 PMCID: PMC6397793 DOI: 10.4240/wjgs.v11.i2.62] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/06/2019] [Accepted: 01/23/2019] [Indexed: 02/06/2023] Open
Abstract
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George’s Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Gaurav Jain
- Transplant and HPB Surgery, the Iowa Clinic-Iowa Methodist Hospital, Des Moines, IA 50309, United States
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Ambe PC, Plambeck J, Fernandez-Jesberg V, Zarras K. The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients. Patient Saf Surg 2019; 13:2. [PMID: 30651756 PMCID: PMC6330420 DOI: 10.1186/s13037-019-0182-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 12/31/2022] Open
Abstract
Background Bile duct injury is the most feared complication during laparoscopic cholecystectomy. Real-time intraoperative imaging using indocyanine green (ICG) might reduce the risk of bile duct injury by improving visualization of the biliary tree during laparoscopic cholecystectomy. We compared the outcomes of laparoscopic cholecystectomy in patients with and without real-time ICG. Methods A retrospective analysis of the data of patients undergoing laparoscopic cholecystectomy with and without ICG in a referral centre for minimally invasive surgery was performed. We hypothesized that laparoscopic cholecystectomy with real-time ICG enables a better identification of the biliary tree and thus increases surgical safety. The outcomes of laparoscopic cholecystectomy with and without ICG were compared using the duration of surgery, the rate of bile duct injury, the rate of conversion, complications and the length of stay. Results Seventy patients including 29 with and 41 without ICG underwent laparoscopic cholecystectomy within the period of investigation. The median duration of surgery was 53.0 vs. 54.0 min while the median length of stay was 2.0 d in the group with and without ICG respectively. The rate of conversion was 2.4% in the group without ICG, while no conversion was performed in the group with ICG. NO bile duct injury occurred in both groups. These differences were not statistically significant. Conclusion Laparoscopic cholecystectomy with real-time indocyanine green fluorescence cholangiography enables a better visualization and identification of biliary tree and therefore should be considered as a means of increasing the safety of laparoscopic cholecystectomy.
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Affiliation(s)
- Peter C Ambe
- 1Department of Visceral, Minimally Invasive and Oncologic Surgery, Marien Hospital Düsseldorf, Rochusstr. 2, 40479, Düsseldorf, Germany.,2Department of Medicine Faculty of health, Witten / Herdecke University, Witten, Germany
| | - Jens Plambeck
- 1Department of Visceral, Minimally Invasive and Oncologic Surgery, Marien Hospital Düsseldorf, Rochusstr. 2, 40479, Düsseldorf, Germany
| | - Victoria Fernandez-Jesberg
- 1Department of Visceral, Minimally Invasive and Oncologic Surgery, Marien Hospital Düsseldorf, Rochusstr. 2, 40479, Düsseldorf, Germany
| | - Konstantinos Zarras
- 1Department of Visceral, Minimally Invasive and Oncologic Surgery, Marien Hospital Düsseldorf, Rochusstr. 2, 40479, Düsseldorf, Germany
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Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention. Int J Surg 2018; 60:164-172. [PMID: 30439536 DOI: 10.1016/j.ijsu.2018.11.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 10/14/2018] [Accepted: 11/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. In this systematic review, the different modalities to aid in the safe performance of LC and prevent BDI are delineated. MATERIALS AND METHODS A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 11 June 2018. RESULTS 90 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative radiologic cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative radiologic cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation. CONCLUSION Given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of alternative techniques is critical to complete surgery with minimal risk of injury to the patient.
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Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ, Endo I, Umezawa A, Asai K, Suzuki K, Mori Y, Okamoto K, Pitt HA, Han HS, Hwang TL, Yoon YS, Yoon DS, Choi IS, Huang WSW, Giménez ME, Garden OJ, Gouma DJ, Belli G, Dervenis C, Jagannath P, Chan ACW, Lau WY, Liu KH, Su CH, Misawa T, Nakamura M, Horiguchi A, Tagaya N, Fujioka S, Higuchi R, Shikata S, Noguchi Y, Ukai T, Yokoe M, Cherqui D, Honda G, Sugioka A, de Santibañes E, Supe AN, Tokumura H, Kimura T, Yoshida M, Mayumi T, Kitano S, Inomata M, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:73-86. [PMID: 29095575 DOI: 10.1002/jhbp.517] [Citation(s) in RCA: 280] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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Affiliation(s)
- Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Horacio J Asbun
- Department of Surgery, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Akiko Umezawa
- Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kenji Suzuki
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tsann-Long Hwang
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Sup Yoon
- Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea
| | - In-Seok Choi
- Department of Surgery, Konyang University Hospital, Daejeon, Korea
| | | | - Mariano Eduardo Giménez
- Chair of General Surgery and Minimal Invasive Surgery "Taquini" University of Buenos Aires, DAICIM Foundation, Buenos Aires, Argentina
| | - O James Garden
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy
| | | | - Palepu Jagannath
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India
| | - Angus C W Chan
- Department of Surgery, Surgery Centre, Hong Kong Sanatorium and Hospital, Hong Kong
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Keng-Hao Liu
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Hsi Su
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Nobumi Tagaya
- Department of Surgery, Dokkyo Medical University Koshigaya Hospital, Saitma, Japan
| | - Shuichi Fujioka
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Yoshinori Noguchi
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Tomohiko Ukai
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Masamichi Yokoe
- Department of General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Daniel Cherqui
- Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Eduardo de Santibañes
- Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina
| | - Avinash Nivritti Supe
- Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, India
| | | | - Taizo Kimura
- Department of Surgery, Fujinomiya City General Hospital, Shizuoka, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan.,Department of EBM and Guidelines, Japan Council for Quality Health Care, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine University of Occupational and Environmental Health, Fukuoka, Japan
| | | | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Koichi Hirata
- Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan
| | | | - Kazuo Inui
- Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan
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Dili A, Bertrand C. Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy. World J Gastroenterol 2017; 23:5438-5450. [PMID: 28839445 PMCID: PMC5550794 DOI: 10.3748/wjg.v23.i29.5438] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/08/2017] [Accepted: 06/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy.
METHODS We present a MEDLINE and PubMed literature search, having used the key-words “laparoscopic intraoperative ultrasound” and “laparoscopic cholecystectomy”. All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed.
RESULTS We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve.
CONCLUSION We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.
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Rose JB, Hawkins WG. Diagnosis and management of biliary injuries. Curr Probl Surg 2017; 54:406-435. [DOI: 10.1067/j.cpsurg.2017.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/20/2017] [Indexed: 12/11/2022]
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Cost-effective Decisions in Detecting Silent Common Bile Duct Gallstones During Laparoscopic Cholecystectomy. Ann Surg 2017; 263:1164-72. [PMID: 26575281 DOI: 10.1097/sla.0000000000001348] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of routine intraoperative ultrasonography (IOUS), cholangiography (IOC), or expectant management without imaging (EM) for investigation of clinically silent common bile duct (CBD) stones during laparoscopic cholecystectomy. BACKGROUND The optimal algorithm for the evaluation of clinically silent CBD stones during routine cholecystectomy is unclear. METHODS A decision tree model of CBD exploration was developed to determine the optimal diagnostic approach based on preoperative probability of choledocholithiasis. The model was parameterized with meta-analyses of previously published studies. The primary outcome was incremental cost per quality-adjusted life year (QALY) gained from each diagnostic strategy. A secondary outcome was the percentage of missed stones. Costs were from the perspective of the third party payer and sensitivity analyses were performed on all model parameters. RESULTS In the base case analysis with a prevalence of stones of 9%, IOUS was the optimal strategy, yielding more QALYs (0.9858 vs 0.9825) at a lower expected cost ($311 vs $574) than EM. IOC yielded more QALYs than EM in the base case (0.9854) but at a much higher cost ($1122). IOUS remained dominant as long as the preoperative probability of stones was above 3%; EM was the optimal strategy if the probability was less than 3%. The percentage of missed stones was 1.5% for IOUS, 1.8% for IOC and 9% for EM. CONCLUSIONS In the detection and resultant management of CBD stones for the majority of patients undergoing laparoscopic cholecystectomy, IOUS is cost-effective relative to IOC and EM.
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Hope WW, Fanelli R, Walsh DS, Narula VK, Price R, Stefanidis D, Richardson WS. SAGES clinical spotlight review: intraoperative cholangiography. Surg Endosc 2017; 31:2007-2016. [PMID: 28364147 DOI: 10.1007/s00464-016-5320-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 12/19/2022]
Affiliation(s)
- William W Hope
- New Hanover Regional Medical Center, 2131 South 17th Street, Wilmington, NC, 28401, USA.
| | | | | | | | - Ray Price
- Intermountain Medical Center, Murray, UT, USA
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Ankersmit M, van Dam DA, van Rijswijk AS, van den Heuvel B, Tuynman JB, Meijerink WJHJ. Fluorescent Imaging With Indocyanine Green During Laparoscopic Cholecystectomy in Patients at Increased Risk of Bile Duct Injury. Surg Innov 2017; 24:245-252. [PMID: 28178882 PMCID: PMC5431362 DOI: 10.1177/1553350617690309] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although rare, injury to the common bile duct (CBD) during laparoscopic cholecystectomy (LC) can be reduced by better intraoperative visualization of the cystic duct (CD) and CBD. The aim of this study was to establish the efficacy of early visualization of the CD and the added value of CBD identification, using near-infrared (NIR) light and the fluorescent agent indocyanine green (ICG), in patients at increased risk of bile duct injury. MATERIALS AND METHODS Patients diagnosed with complicated cholecystitis and scheduled for LC were included. The CBD and CD were visualized with NIR light before and during dissection of the liver hilus and at critical view of safety (CVS). RESULTS Of the 20 patients originally included, 2 were later excluded due to conversion. In 6 of 18 patients, the CD was visualized early during dissection and prior to imaging with conventional white light. The CBD was additionally visualized with ICG-NIR in 7 of 18 patients. In 1 patient, conversion was prevented due to detection of the CD and CBD with ICG-NIR. CONCLUSIONS Early visualization of the CD or additional identification of the CBD using ICG-NIR in patients with complicated cholecystolithiasis can be helpful in preventing CBD injury. Future studies should attempt to establish the optimal dosage and time frame for ICG administration and bile duct visualization with respect to different gallbladder pathologies.
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Abstract
Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.
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Affiliation(s)
- Christopher Molvar
- Department of Radiology, Section of Vascular and Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Bryan Glaenzer
- Department of Radiology, Section of Vascular and Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
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Gong XH, Lu J, Liu J, Deng YY, Liu WZ, Huang X, Yang YH, Xu Q, Yu ZY. Segmentation of Uterus Using Laparoscopic Ultrasound by an Image-Based Active Contour Approach for Guiding Gynecological Diagnosis and Surgery. PLoS One 2015; 10:e0141046. [PMID: 26516767 PMCID: PMC4627783 DOI: 10.1371/journal.pone.0141046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 10/02/2015] [Indexed: 11/18/2022] Open
Abstract
In laparoscopic gynecologic surgery, ultrasound has been typically implemented to diagnose urological and gynecological conditions. We applied laparoscopic ultrasonography (using Esaote 7.5~10MHz laparoscopic transducer) on the retrospective analyses of 42 women subjects during laparoscopic extirpation and excision of gynecological tumors in our hospital from August 2011 to August 2013. The objective of our research is to develop robust segmentation technique for isolation and identification of the uterus from the ultrasound images, so as to assess, locate and guide in removing the lesions during laparoscopic operations. Our method enables segmentation of the uterus by the active contour algorithm. We evaluated 42 in-vivo laparoscopic images acquired from the 42 patients (age 39.1 ± 7.2 years old) and selected images pertaining to 4 cases of congenital uterine malformations and 2 cases of pelvic adhesions masses. These cases (n = 6) were used for our uterus segmentation experiments. Based on them, the active contour method was compared with the manual segmentation method by a medical expert using linear regression and the Bland-Altman analysis (used to measure the correlation and the agreement). Then, the Dice and Jaccard indices are computed for measuring the similarity of uterus segmented between computational and manual methods. Good correlation was achieved whereby 84%-92% results fall within the 95% confidence interval in the Student t-test) and we demonstrate that the proposed segmentation method of uterus using laparoscopic images is effective.
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Affiliation(s)
- Xue-Hao Gong
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People’s Hospital of Shenzhen, Shenzhen, China
| | - Jun Lu
- Department of Ultrasound, Second Clinical College of Jinan University, People’s Hospital of Shenzhen, Shenzhen, China
| | - Jin Liu
- Department of Obstetrics & Gynecology, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Ying-Yuan Deng
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People’s Hospital of Shenzhen, Shenzhen, China
| | - Wei-Zong Liu
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People’s Hospital of Shenzhen, Shenzhen, China
| | - Xian Huang
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People’s Hospital of Shenzhen, Shenzhen, China
| | - Yong-Heng Yang
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People’s Hospital of Shenzhen, Shenzhen, China
| | - Qin Xu
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People’s Hospital of Shenzhen, Shenzhen, China
| | - Zhi-Ying Yu
- Department of Obstetrics & Gynecology, First Affiliated Hospital of Shenzhen University, Shenzhen, China
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Gong XH, Lu J, Liu J, Deng YY, Liu WZ, Huang X, Pirbhulal S, Yu ZY, Wu WQ. A novel ultrasound based approach for lesion segmentation and its applications in gynecological laparoscopic surgery. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2015; 38:709-20. [PMID: 26232250 DOI: 10.1007/s13246-015-0363-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/15/2015] [Indexed: 01/18/2023]
Abstract
Laparoscopic ultrasound (LUS) has been widely utilized as a surgical aide in general, urological, and gynecological applications. Our study summarizes the clinical applications of laparoscopic ultrasonography in laparoscopic gynecologic surgery. Retrospective analyses were performed on 42 women subjects using laparoscopic surgery during laparoscopic extirpation and excision of gynecological tumors in our hospital from August 2011 to August 2013. Specifically, the Esaote 7.5 × 10 MHz laparoscopic transducer was used to detect small residual lesions, as well as to assess, locate and guide in removing the lesions during laparoscopic operations. The findings of LUS were compared with those of preoperative trans-vaginal ultrasound, postoperative, and pathohistological examinations. In addition, a novel method for lesion segmentation was proposed in order to facilitate the laparoscopic gynecologic surgery. In our experiment, laparoscopic operation was performed using a higher frequency and more close to pelvic organs via laparoscopic access. LUS facilitates the ability of gynaecologists to find small residual lesions under laparoscopic visualization and their accurate diagnosis. LUS also helps to locate residual lesions precisely and provides guidance for the removal of residual tumor and eliminate its recurrence effectively. Our experiment provides a safer and more valuable assistance for clinical applications in laparoscopic gynecological surgery that are superior to trans-abdominal ultrasound and trans-vaginal ultrasound.
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Affiliation(s)
- Xue-Hao Gong
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People's Hospital of Shenzhen, Shenzhen, China
| | - Jun Lu
- Department of Ultrasound, Second Clinical College of Jinan University, People's Hospital of Shenzhen, Shenzhen, China
| | - Jin Liu
- Department of Obstetrics & Gynecology, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Ying-Yuan Deng
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People's Hospital of Shenzhen, Shenzhen, China
| | - Wei-Zong Liu
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People's Hospital of Shenzhen, Shenzhen, China
| | - Xian Huang
- Department of Ultrasound, First Affiliated Hospital of Shenzhen University, Second People's Hospital of Shenzhen, Shenzhen, China
| | - Sandeep Pirbhulal
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Zhi-Ying Yu
- Department of Obstetrics & Gynecology, First Affiliated Hospital of Shenzhen University, Shenzhen, China.
| | - Wan-Qing Wu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.
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Peitzman AB, Watson GA, Marsh JW. Acute cholecystitis: When to operate and how to do it safely. J Trauma Acute Care Surg 2015; 78:1-12. [PMID: 25539197 DOI: 10.1097/ta.0000000000000476] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Andrew B Peitzman
- From the Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Ferrero A, Lo Tesoriere R, Russolillo N, Viganò L, Forchino F, Capussotti L. Ultrasound-guided laparoscopic liver resections. Surg Endosc 2014; 29:1002-5. [PMID: 25135446 DOI: 10.1007/s00464-014-3762-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 07/06/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraoperative liver ultrasound has an established role in liver surgery to complete staging and to guide resection. The same performances should be expected by laparoscopic ultrasound (LUS). METHODS LUS is first performed to identify relationships between tumor and vasculo-biliary pedicles. The planes where the main vascular structures run are marked on the liver surface. Parenchymal transection is performed and each vessel recognized during LUS exploration is divided. RESULTS From 01/2009 to 10/2013, in 61 out of 742 liver resections (8.2 %), a laparoscopic approach was attempted. The conversion rate was 9.8 % (six patients). No conversion was related to bleeding or intraoperative complications. The remnant 55 patients were affected by benign lesions in 11 cases and malignant tumors in 44. The resections included 3 left hepatectomies, 14 bisegmentectomies Sg2-3, 5 segmentectomies, and 38 wedge resections. Associated procedures were performed in eight patients (14.5 %), including four colorectal resections. Median duration of surgery was 150 min (60-345 min). Median operative blood loss was 100 mL (0-500 mL). Median size of resected tumor was 2.5 cm (0.9-8 cm). Median surgical margin in oncological resections was 7 mm (0-50 mm). Postoperative complications occurred in four patients (7.2 %), all grade 2 according to Dindo classification. No liver-related morbidity occurred. Median length of hospital stay was 5 days (3-9 days). CONCLUSIONS Ultrasound-guided liver resections can be performed by laparoscopic approach with the same accuracy than open surgery.
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Affiliation(s)
- Alessandro Ferrero
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I", Largo Turati 62, 10128, Turin, Italy
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Gwinn EC, Daly S, Deziel DJ. The use of laparoscopic ultrasound in difficult cholecystectomy cases significantly decreases morbidity. Surgery 2013; 154:909-15; discussion 915-7. [PMID: 24074430 DOI: 10.1016/j.surg.2013.04.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 04/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic ultrasound (LUS) is a method of intraoperative bile duct imaging that can be used prior to any potentially hazardous dissection. The purpose of this study was to determine whether LUS could permit safe laparoscopic completion of difficult cholecystectomy (LC) cases and to assess whether its use had any impact on clinical outcome. METHODS We identified prospectively 44 patients with severe cholecystitis in whom LUS was considered critical for intraoperative identification of the bile ducts. LC patients were compared, on an intention to treat basis, with 41 contemporaneous patients with severe cholecystitis who had planned open cholecystectomy (OC). RESULTS LUS identified the extrahepatic bile ducts in all cases. Of the cases, 40 (91%) were completed laparoscopically. OC patients had a higher rate of acute cholecystitis and preoperative percutaneous cholecystostomy tubes and a higher mean ASA classification. Intraoperatively, LC patients had significantly less estimated blood loss and fewer drains were placed. Postoperatively, LC patients had significantly fewer total complications, Clavien-Dindo grade 3 complications, biliary complications, biliary reinterventions, intra-abdominal abscesses, and bleeding complications. LC patients had significantly fewer ICU admissions and shorter LOS. CONCLUSION By allowing identification of the extrahepatic bile ducts during difficult cholecystectomy, LUS results in a high rate of successful laparoscopic completions. Laparoscopic cholecystectomy is associated with better clinical outcomes than OC for patients with severe cholecystitis.
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Affiliation(s)
- Elizabeth C Gwinn
- Department of General Surgery, Rush University Medical Center, Chicago, IL
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Iannelli A, Paineau J, Hamy A, Schneck AS, Schaaf C, Gugenheim J. Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie. HPB (Oxford) 2013; 15:611-6. [PMID: 23458568 PMCID: PMC3731582 DOI: 10.1111/hpb.12024] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/28/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile duct injuries (BDIs) sustained during a cholecystectomy still remain a major surgical problem, and it is still not clear whether the injury should be repaired immediately or a delayed repair is preferred. METHODS A retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy. RESULTS Forty-seven surgical centres provided 640 cases of bile duct injury sustained during a cholecystectomy of which 543 were analysed for the purpose of the present study. The timing of repair was immediate in 194 cases (35.7%), early in 216 cases (39.8%) and late in 133 cases (24.5%). The type of repair was a suture repair in 157 cases (81%), and a bilio-digestive reconstruction in 37 cases (19%) for immediate repair; a suture repair in 119 cases (55.1%) and a bilio-digestive anastomosis in 96 cases (44.9%) for the early repair; and a bilio-digestive reconstruction in 129 cases (97%) and a suture repair in 4 cases (3%) for late repair. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001). CONCLUSION The timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option.
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Affiliation(s)
- Antonio Iannelli
- Service de Chirurgie Digestive et Transplantation Hépatique, Hôpital Archet 2, Centre Hospitalo Universitaire, Université de Nice Sophia AntipolisNice
| | - Jacques Paineau
- Institut de Cancérologie de l'Ouest René Gauducheau Oncologie ChirurgicaleNantes, France
| | - Antoine Hamy
- Service de Chirurgie Digestive et Endocrinienne, Centre Hospitalier et UniversitaireAngers, France
| | - Anne-Sophie Schneck
- Service de Chirurgie Digestive et Transplantation Hépatique, Hôpital Archet 2, Centre Hospitalo Universitaire, Université de Nice Sophia AntipolisNice
| | - Caroline Schaaf
- Service de Chirurgie Digestive et Transplantation Hépatique, Hôpital Archet 2, Centre Hospitalo Universitaire, Université de Nice Sophia AntipolisNice
| | - Jean Gugenheim
- Service de Chirurgie Digestive et Transplantation Hépatique, Hôpital Archet 2, Centre Hospitalo Universitaire, Université de Nice Sophia AntipolisNice
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A prospective, blinded comparison of laparoscopic ultrasound with transabdominal ultrasound for the detection of gallbladder pathology in morbidly obese patients. J Am Coll Surg 2013; 216:1057-62. [PMID: 23571143 DOI: 10.1016/j.jamcollsurg.2013.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 02/11/2013] [Accepted: 02/12/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transabdominal ultrasound (TAU) is the gold standard for detecting cholelithiasis. Morbid obesity can inhibit detection of gallbladder pathology due to increased subcutaneous and visceral fat. Laparoscopic ultrasound (LUS) has the potential to overcome these technical challenges. We hypothesized that LUS would have a sensitivity and specificity similar to TAU for detecting cholelithiasis and polyps in morbidly obese patients presenting for laparoscopic Roux-en-Y gastric bypass. STUDY DESIGN After Institutional Review Board approval, patients underwent preoperative TAU and intraoperative LUS during laparoscopic Roux-en-Y gastric bypass. Certified ultrasonographers performed all TAUs. Surgeons, blinded to TAU results, performed the LUS. Presence of cholelithiasis or polyps and common bile duct diameter was evaluated. Statistical analysis included chi-square and McNemar's test. RESULTS Two hundred and fifty-three patients were prospectively enrolled during a 6-year period. Seventy-six percent were female, mean age and preoperative body mass index (calculated as kg/m(2)) were 43.5 years and 48, respectively. Mean time to complete the LUS was 4 minutes. Mean common bile duct diameter measured 3.7 mm via LUS and 4.0 mm via TAU. Transabdominal ultrasound and LUS identified 61 and 60 patients with cholelithiasis, respectively (p = 0.763). The sensitivity and specificity of LUS for cholelithiasis was 90.2% and 97.4%. Laparoscopic ultrasound identified polyps in 41 patients, and TAU identified polyps in 6 patients, 5 of which had polyps identified on LUS as well (p < 0.001). Sensitivity and specificity of LUS for polyps was 83.3% and 85.4%. CONCLUSIONS Laparoscopic ultrasound is equivalent to TAU in detecting cholelithiasis, however, LUS detected significantly more polyps. Intraoperative LUS is an appropriate alternative to TAU in patients undergoing laparoscopic Roux-en-Y gastric bypass.
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Intraoperative Ultrasound. Updates Surg 2013. [DOI: 10.1007/978-88-470-2664-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Visceral surgeon and intraoperative cholangiography: Survey about French Wild West surgeons. J Visc Surg 2011; 148:e385-91. [PMID: 22019838 DOI: 10.1016/j.jviscsurg.2011.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cholecystectomy is one of the most common abdominal surgical procedures. No formal agreement has been reached about the routine practice of intraoperative cholangiography (IOC). The purpose of this survey was to describe the practices and the opinions of surgeons in western France. A survey was conducted among 300 visceral surgeons practicing in western France who were asked to respond to a questionnaire with objective and subjective items. One hundred forty-eight answers were interpretable. Among these 148 surgeons, 125 (83.4%) performed IOC routinely (IOCr group) and 23 (15.4%) selectively (IOCs group). Mean age of responding surgeons was 49.3 years. Groups IOCr and IOCs were not significantly different concerning surgical experience. Surgeons in both groups responded that IOC effectively screens for intraoperative bile duct injury. In our survey, routine practice of IOC was more common than reported by our English-speaking colleagues. The routine users responded that IOC can screen for intraoperative bile duct injury or choledocholithiasis. The selective users responded that IOC has its own morbidity. IOC is commonly performed in France during laparoscopic cholecystectomy. Although it may not be indispensable, it allows rapid screening for intraoperative bile duct injury. It also provides documented proof of good surgical practice in the event of a litigation claim after bile duct injury.
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Barros F, Fernandes RA, de Oliveira ME, Pacheco LF, Martinho JMDSG. The influence of time referral in the treatment of iatrogenic lesions of biliary tract. Rev Col Bras Cir 2011; 37:407-12. [PMID: 21340255 DOI: 10.1590/s0100-69912010000600006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 12/05/2009] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To evaluate the prognosis of patients with iatrogenic bile duct injury (IBDI) regarding time of referral (RT) to the unit of liver transplantation (LT). METHODS We reviewed 51 charts of patients who had suffered some kind of IBDI during cholecystectomy and who were referred to the Bonsucesso General Hospital (HGB) LT unit. Lesions were grouped according to the Bismuth classification. Besides cholecystectomy (time of injury), we also evaluated the RT and outcome. RESULTS Among the 51 patients studied, there were 17 men and 34 women, with a mean age of 42.7 years. Twenty-two patients (43.1%) had a type II lesion, 13 (25.5%) type III, 10 (19.6%) type I, 5 (9.8%) type IV and only 1 (2%) type V. Forty patients were operated, and three did not return for medical review, therefore, 37 were evaluated in relation to outcome. Among these, 25 patients (67.6%) had excellent or good results with average RT of 11.5 months (range: 2-48 months) and 47.2 months (range: 3-180 months) respectively. The 12 patients (32.4%) with poor results had a mean RT of 65.9 months (range: 3 264 months), which was significantly higher than the group with excellent or good results (p=0.004). Seven patients were listed for LT, but only two were transplanted. The RT of these seven patients was significantly higher (p=0.04) than those patients not listed. Seven patients died, six of which were due to liver complications. CONCLUSION RT significantly influenced the prognosis of patients in our sample.
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Abstract
INTRODUCTION Since the introduction of laparoscopic cholecystectomy more than two decades ago, the incidence of bile duct injury has remained greater than that established during the era of open cholecystectomy. DISCUSSION This article reviews the common causes of bile duct injury during laparoscopic cholecystectomy and makes recommendations that should help prevent these serious injuries from occurring. CONCLUSIONS The incidence of bile duct injury during laparoscopic cholecystectomy, although greater than during open cholecystectomy, can be minimized using specific operative strategies and dissection principles.
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Affiliation(s)
- Nathaniel J Soper
- Department of Surgery, Northwestern University, 251 E Huron St, Galter 3-150, Chicago, IL 60611, USA.
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Buddingh KT, Nieuwenhuijs VB, van Buuren L, Hulscher JBF, de Jong JS, van Dam GM. Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 2011; 25:2449-61. [PMID: 21487883 PMCID: PMC3142332 DOI: 10.1007/s00464-011-1639-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 01/28/2011] [Indexed: 12/20/2022]
Abstract
Background Bile duct injury (BDI) is a dreaded complication of cholecystectomy, often caused by misinterpretation of biliary anatomy. To prevent BDI, techniques have been developed for intraoperative assessment of bile duct anatomy. This article reviews the evidence for the different techniques and discusses their strengths and weaknesses in terms of efficacy, ease, and cost-effectiveness. Method PubMed was searched from January 1980 through December 2009 for articles concerning bile duct visualization techniques for prevention of BDI during laparoscopic cholecystectomy. Results Nine techniques were identified. The critical-view-of-safety approach, indirectly establishing biliary anatomy, is accepted by most guidelines and commentaries as the surgical technique of choice to minimize BDI risk. Intraoperative cholangiography is associated with lower BDI risk (OR 0.67, CI 0.61–0.75). However, it incurs extra costs, prolongs the operative procedure, and may be experienced as cumbersome. An established reliable alternative is laparoscopic ultrasound, but its longer learning curve limits widespread implementation. Easier to perform are cholecystocholangiography and dye cholangiography, but these yield poor-quality images. Light cholangiography, requiring retrograde insertion of an optical fiber into the common bile duct, is too unwieldy for routine use. Experimental techniques are passive infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. The latter two are performed noninvasively and provide real-time images. Quantitative data in patients are necessary to further evaluate these techniques. Conclusions The critical-view-of-safety approach should be used during laparoscopic cholecystectomy. Intraoperative cholangiography or laparoscopic ultrasound is recommended to be performed routinely. Hyperspectral cholangiography and near-infrared fluorescence cholangiography are promising novel techniques to prevent BDI and thus increase patient safety.
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Affiliation(s)
- K Tim Buddingh
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands.
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Overby DW, Apelgren KN, Richardson W, Fanelli R. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc 2010; 24:2368-2386. [PMID: 20706739 DOI: 10.1007/s00464-010-1268-7] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 12/13/2022]
Affiliation(s)
- D Wayne Overby
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
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Ruiz Gómez F, Ramia Ángel JM, García-Parreño Jofré J, Figueras J. Lesiones iatrogénicas de la vía biliar. Cir Esp 2010; 88:211-21. [DOI: 10.1016/j.ciresp.2010.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 02/21/2010] [Accepted: 03/12/2010] [Indexed: 12/20/2022]
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Abstract
Bile duct injuries incurred during laparoscopic cholecystectomies remain a major complication in an otherwise safe surgery. These injuries are potentially avoidable with proper techniques and correct interpretation of the anatomy. The scope of the injury can range from a simple cystic duct leak to the injury of the left and right hepatic duct confluence. The key to successful outcomes from these injuries is to know when a referral to a specialized tertiary center is necessary. Evaluation and treatment of bile duct injuries is complex and often requires the expertise of an advanced endoscopist, interventional radiologist, and hepatobiliary surgeons. Before any planned intervention or operative repair, detailed evaluation of the biliary system and its associated vasculature is required. Better outcomes are achieved when patients are referred to centers specialized in biliary injury evaluation, treatment, and performing pretreatment planning early.
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Affiliation(s)
- Yuhsin V Wu
- Division of General Surgery, Department of Surgery, Washington University School of Medicine, Surgery House Staff Office, 1701 West Building, Campus Box 8109, 660 South Euclid Avenue, St Louis, MO 63110, USA
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Ishizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N. Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg 2010; 97:1369-77. [PMID: 20623766 DOI: 10.1002/bjs.7125] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although intraoperative cholangiography has been recommended for avoiding bile duct injury during laparoscopic cholecystectomy, radiographic cholangiography is time consuming and may itself cause injury to the bile duct. Recently, a novel fluorescent cholangiography technique using the intravenous injection of indocyanine green (ICG) has been developed. METHODS In 52 patients undergoing laparoscopic cholecystectomy, 2.5 mg ICG was injected intravenously 30 min before the patient entered the operating room or following intubation. A fluorescent imaging system, which consisted of a xenon light source and a laparoscope with a charge-coupled device camera that could filter out light wavelengths below 810 nm, was used. Fluorescent cholangiography was performed during dissection of Calot's triangle, and its ability to delineate biliary anatomy was compared with that of preoperative cholangiography. RESULTS Fluorescent cholangiography delineated the cystic duct in all 52 patients, and the cystic duct-common hepatic duct junction was visible before dissection of Calot's triangle in 50 patients. Fluorescent imaging also identified all accessory bile ducts that had been diagnosed before surgery in eight patients. CONCLUSION Fluorescent cholangiography enables real-time identification of biliary anatomy during dissection of Calot's triangle. This simple technique may become standard practice for avoiding bile duct injury during laparoscopic cholecystectomy, replacing radiographic cholangiography.
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Affiliation(s)
- T Ishizawa
- Department of Surgery, Central Hospital of Social Health Insurance, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Våpenstad C, Rethy A, Langø T, Selbekk T, Ystgaard B, Hernes TAN, Mårvik R. Laparoscopic ultrasound: a survey of its current and future use, requirements, and integration with navigation technology. Surg Endosc 2010; 24:2944-53. [PMID: 20526622 DOI: 10.1007/s00464-010-1135-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 05/06/2010] [Indexed: 01/12/2023]
Abstract
BACKGROUND Laparoscopic ultrasound (LUS) increases surgical safety by allowing the surgeon to see beyond the organ surface, by visualizing vascular structures and by improving surgical precision of tumor resection. A questionnaire-based survey was used to investigate the current use and future expectations of LUS technology. METHODS A questionnaire consisting of 26 questions was distributed manually at four different conferences (60% at the European Association for Endoscopic Surgery (EAES) conference, Stockholm 2008). The answers were summarized with descriptive statistics and nonparametric tests at a significance level of 0.05. RESULTS The questionnaire was answered by 177 surgeons from 40 different countries (85% from Europe). Of these surgeons, 43% use ultrasound during laparoscopic procedures. Generally, more LUS users are found at university hospitals than at general community hospitals. Surgeons use LUS primarily in procedures related to the liver (67% of the surgeons who use LUS), but LUS also is used in other procedures related to the pancreas, biliary tract, and colon. In a 5-year perspective, 82% of surgeons believe in an increased use of LUS, and 79% of surgeons also think that the use of LUS combined with navigation technology will increase and that the most important requirements for such a system are good image quality, easy interpretation, and a high degree of precision. CONCLUSIONS Although the surgeons believe LUS has advantages, only 43% of the respondents reported using it. The surveyed surgeons were largely positive toward an increased use of LUS in a 5-year perspective and believe that LUS combined with navigation technology will contribute to improving the surgical precision of tumor resection.
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Affiliation(s)
- Cecilie Våpenstad
- Department of Medical Technology, SINTEF Technology and Society, 7465, Trondheim, Norway.
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Abstract
OBJECTIVE We aimed to analyze trends in litigation following laparoscopic cholecystectomy (LC) in England and compare our findings with data from the United States. BACKGROUND Several studies from the United States have highlighted the medico-legal repercussions of complications following LC. In 2007-2008, litigation claims cost the National Health Service in England over 660 million Great British Pounds (GBP) (1.1 billion USD). Despite this, there has been little examination of litigation following LC in England. METHODS Data from the National Health Service Litigation Authority on clinical negligence claims between 1995 and 2009 following LC were obtained and analyzed. RESULTS Four hundred eighteen claims were made of which 303 were settled. One hundred ninety-eight (65%) were found to be in the claimants favor for a total cost of 20.4 million GBP (33.4 million USD). Litigation claims have leveled since 2001. Operator error was the most likely cause to result in a claim and the only cause associated with a successful claim (P = 0.023). A delay in the recognition of complications was the second most common reason for initiation of a claim. Bile duct injury was the most frequent injury resulting in litigation and the most likely injury associated with a successful claim (P < 0.001). The average payout for a successful claim was 102,827 GBP/168,337 USD. Findings from US studies were similar, although the magnitude of payouts was 4 times higher. CONCLUSION Strategies that minimize bile duct injury and speed up recognition of injuries should be adopted to reduce the litigation burden and improve patient care.
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Assessment of Common Bile Duct Using Laparoscopic Ultrasound During Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 2009; 19:317-20. [DOI: 10.1097/sle.0b013e3181aa6a3e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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