Knowledge of the cystic artery and its variations is essential to perform safe cholecystectomies. The cystic artery originates from the right hepatic artery, passing posterior to the common hepatic duct, anterior to the cystic duct, and branching into two branches at the neck of the gallbladder. However, variations in position, size, and relationship with adjacent structures are common.

This article presents a literature review regarding cystic artery variations and their frequency during cholecystectomies.

The articles selected for this review were chosen from the PubMed and SciELO databases. The standardized descriptors used were anatomic variation and cholecystectomy. These were chosen using the "Medical Subject Headings" and combined with the Boolean operator AND and the non-standard descriptor cystic artery.

It was found in 54.5% of the studies that the anatomical pattern of the cystic artery was the most frequent type. A different origin from the standard was cited in 63.6% of the articles. Double irrigation of the gallbladder was found in 59.1%. In 36.4%, the cystic artery was anterior to the common hepatic duct or the cystic duct. Cystic arteries outside Calot's triangle were found in 36.4%. Short cystic arteries were found in 13.6%. The absence or non-identification of the artery was reported in 9.1%.

Variations of the cystic artery are common and are frequently reported. One aspect of a safe cholecystectomy is anatomical knowledge and its possible variations. Thus, surgeons must be familiar with this point in order to reduce vascular and biliary injuries.

BACKGROUND Caterpillar hump, also referred to as Moynihan's hump, is a right hepatic artery with tortuous course within the Calot's triangle, which carries a major risk of accidental injury and ligation during laparoscopic cholecystectomy. Its already rare incidence (about 3.81%), in association with the typical presence of 1 or 2 cystic arteries, makes our case unique since it involves a caterpillar hump with 5 distinct arterial branches. CASE REPORT We report a case of caterpillar hump detected during elective laparoscopic cholecystectomy for symptomatic cholelithiasis in a 49-year-old man. A large vessel-like structure with an uncertain termination was initially identified after the hepatocystic triangle dissection. The structure was eventually discovered to have a helical route and re-enter the liver. Although more than 2 elements entered the gallbladder, which exceeded the 'critical view of safety' requirements, a thorough dissection was performed. The surgery is successfully completed when all branches end up in the gallbladder. CONCLUSIONS This report summarizes the clinical and surgical importance of the caterpillar hump, highlighting the necessity for precise anatomical knowledge and the implementation of a "culture of safety" to prevent complications. The concept of "structure" in achieving the "critical view of safety" must encompass its variations and anomalies. Therefore, surgeons must be aware of the potential for multiple arterial branches supplying the gallbladder.

Laparoscopic cholecystectomy is one of the most commonly performed general surgical procedures. Difficult laparoscopic cholecystectomy is associated with increased operative time, hospital stay, complication rates, open conversion, treatment costs, and mortality. This study aimed to provide a comprehensive literature review on difficult laparoscopic cholecystectomy.

A literature search was conducted for articles published in English up to June 2024 using common databases including PubMed/MIDLINE, Web of Science, Google Scholar, and ScienceDirect. Keywords included "safe laparoscopic cholecystectomy", "difficult laparoscopic cholecystectomy", "acute cholecystitis", "prevention of bile duct injuries", "intraoperative cholangiography," "bailout procedure," and "subtotal cholecystectomy". Only clinical trials, systematic reviews/meta-analyses, and review articles were included. Studies involving children, robotic cholecystectomy, single incision laparoscopic cholecystectomy, open cholecystectomy, and cholecystectomy for indications other than gallstone disease were excluded.

Emergency laparoscopic cholecystectomy for acute cholecystitis is ideally performed within 72 h of symptom onset, with a maximum window of 7-10 days. Intraoperative cholangiography can help clarify unclear biliary anatomy and detect bile duct injuries. In the "impossible gallbladder", laparoscopic cholecystostomy or gallbladder aspiration may be considered. When dissection of Calot's triangle is deemed hazardous or impossible, the fundus-first approach allows for completion of the procedure with either total cholecystectomy or subtotal cholecystectomy. Subtotal cholecystectomy is effective in preventing bile duct injuries, can be performed laparoscopically, and is currently the best available bailout approach for difficult laparoscopic cholecystectomy.

Difficult laparoscopic cholecystectomy is a common clinical scenario that requires a judicious approach by experienced surgeons in appropriate settings. When difficult laparoscopic cholecystectomy is encountered, various bailout strategies are available. Currently, subtotal cholecystectomy is likely the most effective bailout approach.

Background: With improvements in skills and evidence of safety, emergent laparoscopic cholecystectomy is routinely performed for acute cholecystitis, if indicated, at our hospital. However, resident operations are concerned with the dilemmas of training programs and patient safety. Hence, our aim was to clarify the safety and feasibility of emergency laparoscopic cholecystectomy performed by attending surgeons and residents. Materials and Methods: Our study was a retrospective review of 923 patients, who underwent laparoscopic cholecystectomy between January 2021 and June 2022 at our hospital. We excluded combined surgery, single-port methods, laparoscopic common bile duct exploration, elective surgery, and patients with Mirizzi symptoms. Of the 191 patients who underwent emergency laparoscopic cholecystectomy, 118 were operated on by residents, and 73 were operated on by attending surgeons. Patient demographics, surgical and postoperative outcomes, and length of hospital stay were compared between the groups. Results: No significant differences were observed in sex, age, body mass index (BMI), or surgical history. Older age (60 versus 52 years) and higher BMI (26.29 versus 25.46) were observed in the attending group, and the severity was greater than that in the resident group. No significant differences were observed in the operative results, including mortality (both groups, n = 0), morbidity, blood loss, or length of stay. However, the operation time was significantly shorter in the attending group obviously (86.41 versus 117.89 minutes, P < .0001) significantly. Conclusion: Emergent laparoscopic cholecystectomy for acute cholecystectomy performed by a resident under supervision appears feasible and safe. The resident operator was associated with increased operative times, however, not complications. This study confirms that residents can also finish surgery in precisely selected cases, and the more important concept is knowing the limits of asking for help.

Nefopam is a safe analgesic with mild side effects including drowsiness, nausea, vomiting, and sweating. Nevertheless, research is scarce on the impact of nefopam in managing postoperative pain following laparoscopic cholecystectomy (LC), and the advantageous effects of nefopam remain unclear. In this research, the effectiveness of nefopam was compared to placebo for the treatment of postoperative pain following LC.

A literature search for randomized controlled trials (RCTs) was performed through June 2024 using online databases including Cochrane Library, PubMed/Medline, and Web of Science. The primary outcome assessed was the quality of postoperative patient pain, and the secondary outcome was side effects that occurred due to the use of nefopam. The Cochrane Risk of Bias (RoB) 2 tool was used to assess the RoB. The meta-analysis was conducted using Review Manager software version 5.4. The risk ratio (RR), mean difference (MD), and standardized mean difference (SMD) were calculated at 95% confidence intervals (CIs).

Five RCTs comprising 254 participants were analyzed. The analysis revealed that compared to placebo, nefopam had no statistically significant effect on the reduction of postoperative pain severity at 30 min (SMD = -0.30, 95% CI: -0.61 to 0.01; P = 0.06) and 60 min (SMD = -0.31, 95% CI: -0.78 to 0.16; P = 0.20). Nefopam reduced the number of opioids taken, as shown in the meta-analysis (SMD = -0.94, 95 CI: -1.35 to -0.53; P < 00001), with minor heterogeneity (P = 0.24, I2 = 30%). This meta-analysis showed that nefopam lengthened the time to first rescue analgesia (MD = 23.003). and markedly reduced the number patients requiring analgesics compared to baseline (RR = 0.34, 95% CI: 0.22 to 0.54; P < 0.00001).

Nefopam did not cause any difference in total postoperative pain but was effective in reducing overall opioid consumption and the need for supplementary analgesics. It did not increase postoperative nausea and vomiting.

Subtotal cholecystectomy is one of the most frequent bail-out procedures performed during difficult cholecystectomy. A common complication to this procedure is bile leak, and thus multiple strategies have been created to avoid its appearance. This study aims to evaluate the effectivity of using an omental patch as bile leak prevention in patients undergoing subtotal cholecystectomy. A retrospective cohort study including patients who underwent subtotal cholecystectomy between 2014 and 2022 was performed. 17 patients had an omental patch, while 378 did not; the latter were included to evaluate surgical outcomes with bile leak as a primary outcome using a propensity score matching analysis (PSM). Patients' median age in both groups after PSM was 71.00 (IQR: 59.00-81.00) and 69.00 (IQR: 61.75-80.25) years, respectively. The dominant sex in both groups was male. In most cases surgical procedure indication was cholecystitis. Patients who had an omental patch did not present statistically significant differences for bile leak rates compared to patients who did not (29.4% versus 17.6%, p = 0.456, respectively). Similar results were observed when evaluating the need for postoperative ERCP for bile leak management (23.5 versus 5.9%, p = 0.078). A statistically significant higher proportion of major complications were observed in patients who had an omental patch (47.1% versus 19.1%, p = 0.038). Pedicled omental patch was not an effective measure for preventing bile leak, and it even presented a higher rate of complications. It is thus imperative to continue evaluating other strategies for the prevention of bile leak during subtotal cholecystectomy.

Different techniques have been proposed to reduce the incidence of the intraoperative bile duct injury during laparoscopic cholecystectomy (LC). Among these, Near-Infrared Fluorescence Cholangiography (NIFC) with Indocyanine Green (ICG) represents a relatively recent addition. At present, there is considerable variation in the protocols for the administration of ICG.

The aim of this randomized multicenter clinical trial (RCT) is to ascertain whether there are differences between the dosage and administration intervals of ICG, with a view to optimizing a good-quality NIFC during LC. Furthermore, an analysis was conducted to determine the potential impact of different factors on the outcomes of this technique. The trial was approved by the local institutional Ethics Committee.

From June 2022 to June 2023, 200 patients were randomized in four arms (G1: 2.5 mg ICG > 3 h prior to surgery, G2: 2.5 mg ICG 15-30 min prior to surgery, G3: 0.05 mg/kg ICG > 3 h prior to surgery and G4: 0.05 mg/kg ICG 15-30 min prior to surgery). We found differences in the DISTURBED score between the groups (p < 0.001), suggesting that ICG administration 15-30 min before surgery was worse than administration > 3 h after LC (p = 0.02). Additionally, it was observed that body mass index (BMI), gender, ASA Classification System, previous liver and biliary disease and the type of surgery had influence on NIFC. Finally, the NIFC had an impact in intraoperative and postoperative complications, operative time and hospital length of stay.

The administration of ICG > 3 h improve liver background fluorescence in the NIFC during LC. There are different factors may affect NIFC results (BMI, ASA grade, previous liver disease, presence of gallbladder inflammation and type of surgery). Finally, high-quality NIFC was associated with fewer surgical complications, shorter surgical time and shorter length of hospital stay.

In this study, we propose a critical view of safety to promote standard visual identification and preservation of RLN during TOETVA. Laryngoscope, 135:1227-1228, 2025.

The protective impact of the Critical View of Safety (CVS) approach on the vasculo-biliary injuries during laparoscopic cholecystectomy (LC) depends largely upon the understanding of the normal and variant anatomy. Structures exposed during the acquisition of the CVS can deviate from the typical dual configuration of the cystic duct and artery (gallbladder pedicle) representing either a third (supernumerary) or atypical in course (heterotopic) element. The aim of this study was to determine the identity and the frequency of these anatomical elements and to propose anatomic schemata that can guide the achievement of CVS by surgeons.

Fourteen anatomic elements that can be encountered during LC were defined by members of the Hellenic task force on the typology of safe cholecystectomy using a literature review and expert consensus. Videos of 279 LCs performed for biliary colic were reviewed noting the presence of a third and or heterotopic anatomic element. In 108 LCs these elements were sought also intraoperatively. A CVS score according to Sanford and Strasberg was assigned to each video.

The normal configuration of the gallbladder pedicle was present in 233 cases (83.51%). A third element was detected in 42 cases (15.05%) and was arterial in 41 cases and biliary in 1 case. A heterotopic course concerned exclusively the cystic artery in 24 cases (8.6%). Neither of these two variant patterns compromised achievement of the CVS during LC. CVS scores improved with the addition of intraoperative assessment.

Typical and aberrant anatomy of LC was defined and anatomic schemata proposed to help the surgeon better understand aberrant anatomy and confidently and safely handle any encountered element that deviates from the normal configuration of the gallbladder pedicle during laparoscopic cholecystectomy.

The cystic artery is a critical anatomical landmark in both laparoscopic and open cholecystectomy. This report presents a unique case involving two rare anatomical variations: double cystic arteries, along with a superficial branch originating from the superior mesenteric artery (SMA) - a previously unreported combination with significant clinical and surgical implications. Unlike earlier studies, this research provides detailed anatomical and embryological insights supported by high-quality imaging and illustrations to guide surgeons in recognizing and managing this novel variation. The cadaver examined in this study was donated to the Griffith University School of Medicine for medical education and research. A macroscopic examination was conducted to identify anatomical variations and elucidate the relationships between the atypical cystic artery and surrounding abdominal structures. The typical cystic artery originated from the right hepatic artery, passing posterior to the common hepatic duct within the hepatocystic triangle to supply the superomedial (dorsal/deep) surface of the gallbladder. An accessory cystic artery (100 mm long, 2.5 mm in diameter) originated 35 mm distal to the SMA origin, with a retro-pancreatic and sub-hepatocystic course, bifurcating to supply the cystic duct and the inferolateral (superficial) surface of the gallbladder. This configuration, resembling an aberrant right hepatic artery in size and position, poses heightened risks of bleeding and injury during laparoscopic hepatoduodenal ligament dissection, duodenal mobilization, and in the presence of pancreatic inflammatory or neoplastic processes. By addressing a significant gap in the literature, this study advances both anatomical knowledge and surgical safety. Understanding such variations can significantly improve the safety and efficacy of cholecystectomies and other hepatobiliary, duodenal, and pancreatic surgical procedures. In select cases, preoperative imaging such as computed tomography angiography and collaboration with radiologists can aid in detecting vascular anomalies and guiding surgical planning.

Background and objectives: Laparoscopic cholecystectomy (LC) is the most commonly performed operation in general surgery in the Western World. Gallbladder surgery, although most of the time simple, always offers the possibility of unpleasant surprises. Despite progress, the incidence of common bile duct injury is 0.2-0.4%, causing devastating implications for the patient and the surgeon. This is mainly due to the failure to identify the normal anatomy properly. The literature review reveals a lack of structured knowledge in the surgical anatomy of cholecystectomy. The aim of this study was to develop a framework with a common anatomical language for safe laparoscopic and open cholecystectomy. Materials and Methods: The Hellenic Task Force group on the typology for Safe Laparoscopic Cholecystectomy performed a critical review of the literature on the laparoscopic anatomy of cholecystectomy. The results were compared with those of a clinical study of 279 patients undergoing LC for uncomplicated symptomatic gallstone disease. Results: Fourteen elements encountered during LC under the critical view of safety (CVS) approach were determined. The typical vascular-biliary pedicle with one cystic duct distributed laterally (or caudally) and one cystic artery medially (or cranially) lying at any point of the hepatocystic space was found in 66% of the cases studied. Anatomical schemata were formulated corresponding to the norm and four variations. Conclusions: The proposed cognitive anatomical schemata summarize simply what one can expect in terms of deviation from the norm. We believe that the synergy between the correct application of the CVS and the structured knowledge of the surgical anatomy in cholecystectomy helps the surgeon to handle non-typical structures safely and to complete the laparoscopic or open cholecystectomy without vascular-biliary injuries.

Background and Objectives: Laparoscopic cholecystectomy constitutes the current "gold standard" treatment of symptomatic gallstone disease. In order to avoid intraoperative vasculobiliary injuries, it is mandatory to establish the "critical view of safety". In cases of poor identification of the cystic duct and artery leading to a missed intraoperative injury, patients present with elevated liver function tests (LFTs) or increased bilirubin postoperatively. The aim of this study is to present a series of patients of our institute with elevated liver enzymes and bilirubin after laparoscopic cholecystectomy in the absence of intraoperative injury or any other obvious etiology and to provide a possible explanation of this finding. Materials and Methods: From 2019 to 2023, 200 patients underwent elective laparoscopic cholecystectomy at the Papageorgiou General Hospital and at the European Interbalkan Medical Center of Thessaloniki utilizing the "critical view of safety" method. We retrospectively collected the intraoperative reports, and the pre- and postoperative imaging and laboratory studies of the patients included in this series. Postoperative LFTs and bilirubin levels were extracted and the reason for their transient elevation was examined. Results: From 200 cases of laparoscopic cholecystectomy, elevated LFTs and bilirubin were found in six patients on the first postoperative day, which is suggestive of a missed intraoperative injury. All patients were asymptomatic. During the investigatory workup, a triple-phase CT of the liver and/or an MRCP were ordered, but no pathological findings, such as biliary injury, hepatic artery injury or choledocholithiasis, were found. On postoperative day 3, LFTs and bilirubin levels decreased or normalized without any intervention. No postoperative complications were reported. Conclusions: In select cases, a transient increase in LFTs and/or bilirubin may be observed in the early postoperative period after elective laparoscopic cholecystectomy in the absence of an obvious etiology. A possible interpretation of these findings could involve the pneumoperitoneum or the anesthesia regimens used intra- or perioperatively. The specific cause, however, remains undetermined and yet to be examined by future studies.

Bile duct injuries (BDIs) are dreaded complications of one of the most common general surgical procedures. The injury impacts the quality of life and may have several long-term complications. In some cases, it can also lead to mortality. This paper aims to review works that have already been published about bile duct injuries and elaborate on the factors leading to it. This includes elaborating on both surgical and non-surgical factors. It also plans to highlight practices and methods to avoid BDIs. Medical research databases were searched using cholecystectomy and bile duct injuries as keywords. Papers including pre-operative or intraoperative factors, that may cause bile duct injuries, were further shortlisted for this study. Understanding and knowledge of anatomy plays a key role in bile duct injuries and is essential before performing the surgery. Factors related to the patients, surgeons, and logistics also play a major role in causing bile duct injuries. Bile duct injuries can be reduced using certain strategies like the B SAFE strategy, R4U line, bail-out methods, imaging techniques along with referrals to Hepatobiliary specialist centers to avoid bile duct injuries.

Cholecystectomy is the most common general surgery procedure, necessitating thorough knowledge of bile duct anatomy. Despite the bile duct's anatomical diversity, reports of double cystic ducts are rare. This case presentation aims to emphasize the importance of recognizing this unusual anatomical variant during surgical procedures to prevent complications and ensure patient safety.

This is a 22-year-old woman with a history of lupus. Initial clinical and ultrasound evaluations concluded she had cholangitis, choledocholithiasis, and cholecystitis. A cholecystectomy was performed, during which a double cystic duct was identified and confirmed with intraoperative cholangiography. Five days after surgery, the patient exhibited increased bilirubin levels, and a follow-up cholangiography showed dilation of the common bile duct with no passage of contrast medium into the duodenum. She underwent ERCP with endoprosthesis placement and is currently under follow-up with adequate progress.

Double cystic ducts are extremely rare anatomical variants. These variations pose significant challenges for surgeons during surgery, emphasizing the need for a universal culture of safety during cholecystectomy. Although this anatomical variant is rare, surgeons must be aware of it. Given the uncertainty of anatomy, it is advisable to perform intraoperative imaging, such as cholangiography, before sectioning any duct.

Double cystic duct variations are rare, but when bile duct anatomy is unclear, intraoperative cholangiography is essential. This technique improves visualization of biliary structures, aiding informed decisions before duct ligation and reducing the risk of bile duct disruption.

To potentially lessen injuries and associated complications, fluorescence cholangiography has been suggested as a technique for enhancing the visualization and identification of extrahepatic biliary anatomy. The most popular way to administer indocyanine green (ICG) is intravenously, as there is currently little data on ICG injections directly into the gallbladder. In order to visualize extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC), we compared the two different ICG administration techniques. We also examined variations in visualization time, as well as the effectiveness, benefits, and drawbacks of each modality.

In this prospective randomized clinical study, 60 consecutive adult patients with chronic and acute gallbladder disease were included. Our study conducted from 2022 to 2024 in Surgical Department of Theodor Bilharz Research Institute. Thirty patients underwent LC with intravenous ICG administration (IV-ICG), thirty patients received a direct injection of gallbladder through transhepatic ICG (IC-ICG) and Preoperative, intraoperative, and postoperative patient data were examined.

In terms of their perioperative and demographic features, the groups were similar. Without a statistically significant difference, the IV-ICG group's total operating time was less than that of the IC-ICG group (p 0.140). Compared to the transhepatic IC-ICG method, IV-ICG was more accurate in identifying the duodenum and the common hepatic duct (p = 0.029 and p = 0.016, respectively). In the transhepatic IC-ICG and IV-ICG groups, the cystic duct could be identified prior to dissection in 66.6% and 73.3% of cases, respectively, and this increased to 86.6% and 93.3% following dissection. In the transhepatic IC-ICG group, the common bile duct was visible in 93.3% of cases; in the IV-ICG group, it was visible in 90% of cases. Two cases in the IC-ICG group and every case following IV-ICG administration had liver fluorescence (6.6% versus 100%; p < 0.001).

The current study shows that for both administration methods, ICG-fluorescence cholangiography can be useful in identifying the extrahepatic biliary anatomy during Calot's triangle dissection. By avoiding hepatic fluorescence, the transhepatic IC-ICG route can increase the bile duct-to-liver contrast with less expense and no risk of hypersensitivity reactions than the intravenous ICG injection method. We recommend to use both techniques in case of acute cholecystitis with cystic duct obstruction. In cases of liver cirrhosis, we recommend transhepatic IC-ICG as IV-ICG is limited.

Symptoms of gallstone disease are the most common reason for cholecystectomy. Fenestration reduces the likelihood of severe inflammation or scarring after normal treatments are used, and it also enhances control over bile outflow. The goal of reconstituted cholecystectomy is to lessen symptoms like pain and jaundice without undergoing the high-risk procedures associated with more invasive procedures. The reconstituted and fenestrated procedures were assessed by a meta-analysis and systematic review. Of the five studies, 189 (34.2%) had a reconstituted subtotal cholecystectomy, and 363 (65.8%) had a fenestrated subtotal cholecystectomy, which had populations from the United States of America, the United Kingdom, Japan, and Turkey. Two individuals from three trials had bile duct injury, according to three studies. Whereas the fenestrated group reported no bile injury from 236 individuals (0%), the reconstituted group reported two bile duct injuries from 100 patients (2%). The incidence was found to be lower in the fenestrated group (OR 10.81; CI 95% 1.03-113.65; p = 0.39; I2 = 0%) than in the reconstituted group. Four studies revealed 92 cases of bile leaks: 19 out of 155 cases (12.3%) were reconstituted, and 73 out of 351 cases (20.8%) were fenestrated. Between the two groups, there was a significant difference in bile leakage (OR 0.72; CI 95% 0.23-2.32; p = 0.03; I2 = 66%). Two studies reported the establishment of fistulas following surgery in 58 patients in the reconstituted group (5.2%) and 120 patients in the fenestrated group (2.5%) (p = 0.56, I2 = 0%, and OR 0.65; CI 95% 0.12-3.38); however, there was no statistically significant difference between the groups. Following a fenestrated partial cholecystectomy, postoperative bile leakage, fistula development, wound infection, and retained stones are more prevalent. Additionally, we saw that the fenestrated method was being used more frequently for post-operative endoscopic retrograde cholangiopancreatography (ERCP). The subtotal cholecystectomy technique used should be chosen according to the surgeon's comfort level and experience with the various techniques and intraoperative findings, even if the reconstituted procedure could be preferred when feasible. To completely understand the role of each method in the general surgeon's toolkit for treating complex gallbladder (GB) patients, longer-term follow-up studies are still necessary.

The severity of surrounding adhesions, anomalous anatomy, and technical issues are the main factors that complicate cholecystectomy. This study focused on determining the types and frequency of laparoscopic anatomical variations found during laparoscopic cholecystectomy in our limited-resources condition and on defining the safe zone of dissection.

This prospective study was conducted at a single center in Aden, Yemen from 2012 to 2019. A total of 375 patients, comprising 355 females (94.7%) and 20 males (5.3%), presented with symptomatic gallbladders and underwent standard four-port laparoscopic cholecystectomy. The regional laparoscopic variations were evaluated and recorded.

Of the 375 patients, 26 (6.9%) had laparoscopic anatomical variations, of whom 19 (73.1%) had vascular variations and seven (26.9%) had ductal variations. The anatomical variations included the following: double cystic artery of separated origin, seven cases (26.9%); Moynihan's hump, six (23.1%); double cystic artery of single origin, four (15.4%); thin long cystic duct, four (15.4%); subvesical duct, three (11.5%); and cystic artery hocking the cystic duct, two (7.7%).

Biliary anatomical variations can be expected in any dissected zone. Most of the detected variants were associated with the cystic artery. An overlooked accessory cysto-biliary communication can cause complicated biliary leakage. A surgeon's skills and knowledge of laparoscopic anatomical variants are essential for performing a safe laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

Background Cholecystectomy, the surgical removal of the gallbladder, is a common procedure performed to treat conditions like gallstone disease and cholecystitis. Among the various techniques available, laparoscopic cholecystectomy (LC) and robotic cholecystectomy (RC) are minimally invasive methods, while open cholecystectomy (OC) involves a more extensive incision and is reserved for cases where less invasive options are unsuitable. This study focuses on evaluating and comparing the safety and efficacy of LC and RC across different grades of cholecystitis, categorized by the Parkland Grading Scale. The goal is to determine whether RC provides significant benefits over LC, particularly in cases of higher-grade cholecystitis. Methodology This ambispective observational case-control study was conducted from January to June 2024 at Manipal Hospitals, Vijayawada, India. It included patients aged 18 or older with acute cholecystitis who underwent LC or OC. Exclusions were made for chronic cholecystitis, prior surgeries affecting the procedure, incomplete records, or severe complications. Data, including demographics, preoperative symptoms, intraoperative details, and postoperative outcomes, were extracted from electronic medical records. Laparoscopic procedures used standard techniques, while robotic procedures employed the da Vinci surgical system. Outcomes measured included operative time, complications, conversion rates, length of stay, and readmission rates. Results There was no significant difference in pre-operative parameters like age, white blood cell (WBC) count, total bilirubin, alanine transaminase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), or history of previous surgery according to the Parkland Grading Scale. However, differences were noted in the Parkland Grading Scale regarding the thickness of the gallbladder wall, incidence of pericholecystic collection, and history of acute cholecystitis (p < 0.05). The most common complication was bleeding during the operation, which was more frequent in LC and was significant. Other complications, such as bile duct injury and vascular injury, were not observed in either procedure. Conclusion This study highlights that RC provides notable benefits compared to LC, especially for higher grades of cholecystitis, as per the Parkland Grading Scale. Although robotic procedures have longer operative times, they result in fewer intraoperative and postoperative complications, reduced conversion rates, and lower readmission rates. These advantages make RC a promising choice for treating complex cases of cholecystitis.

Mirizzi syndrome, although rare, is a potential complication of long-standing gallstone disease, particularly cholecystolithiasis. Due to the nonspecific nature of its symptoms, this condition often remains undiagnosed prior to surgery in most cases. While minimally invasive approaches are generally safe in expert hands, they can be challenging and entail the risk of bile duct injuries, often necessitating conversion to bail-out procedures. Delayed management of Mirizzi syndrome can lead to serious consequences, such as empyema of the gallbladder (GB), gangrene of the GB wall, perforation, and sepsis. Intraoperative indocyanine green fluorescence imaging during laparoscopic cholecystectomy can help delineate the biliary anatomy and prevent biliary tract injuries in difficult GBs like Mirizzi syndrome.

The aim of this study is to evaluate morbidity and mortality in patients taken to conversion to open procedure (CO) and subtotal laparoscopic cholecystectomy (SLC) as bailout procedures when performing difficult laparoscopic cholecystectomy.

This observational cohort study retrospectively analyzed patients taken to SLC or CO as bailout surgery during difficult laparoscopic cholecystectomy between 2014 and 2022. Univariable and multivariable logistic regression models were used to identify prognostic factors for morbimortality.

A total of 675 patients were included. Of the 675 patients (mean [SD] age 63.85 ± 16.00 years; 390 [57.7%] male) included in the analysis, 452 (67%) underwent CO and 223 (33%) underwent SLC. Overall, neither procedure had an increased risk of major complications (89 [19.69%] vs 35 [15.69%] P.207). However, CO had an increased risk of bile duct injury (18 [3.98] vs 1 [0.44] P.009), bleeding (mean [SD] 165.43 ± 368.57 vs 43.25 ± 123.42 P < .001), intestinal injury (20 [4.42%] vs 0 [0.00] P.001), and wound infection (18 [3.98%] vs 2 [0.89%] P.026), while SLC had a higher risk of bile leak (15 [3.31] vs 16 [7.17] P.024). On the multivariable analysis, Charlson comorbidity index (odds ratio [OR], 1.20; CI95%, 1.01-1.42), use of anticoagulant agents (OR, 2.56; CI95%, 1.21-5.44), classification of severity of cholecystitis grade III (OR, 2.96; CI95%, 1.48-5.94), and emergency admission (OR, 6.07; CI95%, 1.33-27.74) were associated with presenting major complications.

SLC was less associated with complications; however, there is scant evidence on its long-term outcomes. Further research is needed on SLC to establish if it is the safest in the long-term as a bailout procedure.

A critical view of safety (CVS) is important to ensure safe laparoscopic cholecystectomy. When the CVS is not possible, subtotal cholecystectomy is performed. While considering subtotal cholecystectomy, surgeons are often concerned about preventing bile leakage from the cystic ducts. The two main types of subtotal cholecystectomy for acute cholecystitis are fenestrating and reconstituting. Previously, there were no selection criteria for these two; therefore, open conversion was performed. This study aimed to evaluate our goal-oriented approach to choose fenestrating or reconstituting subtotal cholecystectomy for acute cholecystitis.

We introduced our goal-oriented approach in April 2019. Before introducing this approach, laparoscopic cholecystectomy for acute cholecystitis was performed without criteria for subtotal cholecystectomy. After our approach was introduced, laparoscopic cholecystectomy for acute cholecystitis was performed according to the subtotal cholecystectomy criteria. We retrospectively reviewed the medical records of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2015 and 2021. Laparoscopic cholecystectomy for acute cholecystitis was performed by surgeons regardless of whether they were novices or veterans.

The period from April 2015 to March 2019 was before the introduction (BI) of our approach, the period from April 2019 to December 2021 was after the introduction (AI) of our approach. There were 177 and 186 patients with acute cholecystitis during the BI and AI periods, respectively. There were no significant differences between groups in terms of preoperative characteristics, operative time, and blood loss. No difference in the laparoscopic subtotal cholecystectomy rate between groups (10.2% [BI] vs. 13.9% [AI]; p = 0.266) was obserbed. The open conversion rate during the BI period was significantly higher than that during the AI period (7.4% vs. 1.6%; p = 0.015).

Our goal-oriented approach is feasible, safe, and easy for many surgeons to understand.

Laparoscopic cholecystectomy, introduced in 1985 by Prof. Dr. Erich Mühe, has become the gold standard for treating chronic symptomatic calculous cholecystopathy and acute cholecystitis, with an estimated 750,000 procedures performed annually in the United States of America. The risk of iatrogenic bile duct injury persists, ranging from 0.2 to 1.3%. Risk factors include male gender, obesity, acute cholecystitis, previous hepatobiliary surgery, and anatomical variations in Calot's triangle. Strategies to mitigate bile duct injury include the Critical View of Safety and fundus-first dissection, along with intraoperative cholangiography and alternative approaches like subtotal cholecystectomy.

This paper introduces the shoeshine technique, a maneuver designed to achieve atraumatic exposure of anatomical structures, local hemostatic control, and ease of infundibulum mobilization. This technique involves the use of a blunt dissection tool and gauze to create traction and enhance visibility in Calot's triangle, particularly beneficial in cases of severe inflammation. Steps include using the critical view of safety and Rouviere's sulcus line for orientation, followed by careful dissection and traction with gauze to maintain stability and reduce the risk of instrument slippage.

The technique, routinely used by the authors in over 2000 cases, has shown to enhance patient safety and reduce bile duct injury risks.

The shoeshine technique represents a simple and easy way to apply maneuver that can help surgeon during laparoscopic cholecystectomies exposing the hepatocystic area and promote blunt dissection.

Cholecystectomy is one of the most common operations performed worldwide. Although laparoscopic surgery has been the 'gold-standard' approach for this operation, there is a paucity of global evidence around the variations of safe provision of cholecystectomy, including low-income and middle-income countries. This international collaborative study will allow contemporaneous data collection on the quality of cholecystectomies using measures covering infrastructure, care processes and outcomes, with the primary aim define the global variation in compliance with preoperative, intraoperative and postoperative audit standards.

Global Evaluation of Cholecystectomy Knowledge and Outcomes is a prospective, international, multicentre, observational cohort study delivered by the GlobalSurg Collaborative. Consecutive patients undergoing cholecystectomy between 31 July 2023 and 19 November 2023 will be recruited, with follow-up at 30 days and 1-year postoperatively. The study will be undertaken at any hospital providing emergency or elective surgical services for biliary disease. The primary endpoint of this study is compliance with preoperative, intraoperative and postoperative audit standards. Secondary outcomes include rates of 30-day complications, achievement of critical view of safety and rates of gallbladder cancer.

This project will not affect clinical practice and has been classified as clinical audit following research ethics review at University Hospital Birmingham NHS Trust. The protocol will be disseminated through the international GlobalSurg and CovidSurg network.

NCT06223061.

To investigate the clinical characteristics of symptomatic cholecystolithiasis and laparoscopic cholecystectomy complications in pediatric patients.

The medical records of 50 children and adolescents who underwent laparoscopic cholecystectomy were analyzed. We evaluated gender, age, body mass index, preoperative clinical aspects, perioperative complications, and gallstone composition.

Among the patients, 33 (66%) were female, and 17 (34%) were male. The mean age was 11.4 ± 3.6. All patients were diagnosed with cholecystolithiasis by abdominal ultrasonography. Twelve patients (24%) had hematological disease: eight (16%) with sickle cell anemia and four (8%) with hereditary spherocytosis. Thirteen patients (26%) were obese. Twelve patients (24%) had complicated biliary disease. During the intraoperative period, three patients (6%) had excessive bleeding in the hepatic hilum, and one had an accidental injury to the common bile duct. Three (6%) postoperative complications (acute pancreatitis, common bile duct stenosis, and intestinal obstruction) were observed. Among 28 patients (56%), 25 (50%) had cholesterol gallstones, and three (6%) had bile pigment gallstones.

The evolution of cholecystolithiasis in the pediatric population can present serious complications, emphasizing the need to avoid temporizing cholecystolithiasis in children and adolescents because laparoscopic cholecystectomy in this group is safe, with low complication rates.

The modern-day gold standard treatment of acute cholecystitis is laparoscopic surgery. It is, however, associated with a higher risk of bile duct injury (0.1 %-1.5 %) when compared to the open approach.

We report a case of a patient with an acute cholecystitis in which we performed a laparoscopic cholecystectomy. We faced a destabilizing anatomy with what looked like the gallbladder and an unidentified mass, interpreted as a possible common bile duct cyst. Careful dissection allowed us to determine that what looked like a common bile duct cyst was a dilatation of "Hartmann's pouch" due to a large gallstone.

Laparoscopic cholecystectomy reduces length of hospitalization and enhance intra-operative and postoperative morbidity compared with open cholecystectomy. It may increase the risk of bile duct injury, notably in an acute setting due to inflammation and an unclear anatomy. Hartmann's pouch with the infundibulum can sometimes unexpectedly be present beneath the common hepatic duct. In order to avoid bile duct injury, notably in an acute setting, a surgical technique was developed, the Critical View of Safety. It is a method whose sole aim is to secure identification of the cystic structures.

Understanding the anatomy allowed for an ultimately safe laparoscopic cholecystectomy. It is strongly advised that, in the event of atypical anatomy, a second opinion is asked of another and/or more experimented surgeon.

An alternative method to standard laparoscopic cholecystectomy (SLC) is the "fundus first" method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level.

In GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006-2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20-79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time.

No difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14-0.86]) and gallbladder perforation (OR 0.61 [0.45-0.82]) were significantly lower in the "fundus first > 80% group" and the operative time was shorter (OR 0.76 [0.69-0.83]).

In this study including >160,000 cholecystectomies, both methods was found to be equally safe.

During laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

This case shows the need for in-depth knowledge also on congenital biliary anomalies that can become subject to iatrogenic damage. The patient is 44-years old with echographically proven cholelithiasis with complaints of intermittent pain in the right upper quadrant. During laparoscopic cholecystectomy, after identification of cystic duct and cystic artery, after their clipping and resection and subsequent mobilization of the gallbladder from the liver parenchyma, a bile duct was opened. Subsequent identification revealed a cystohepatic duct, which is a rare anatomic anomaly. Plastic surgery was performed on the tangential lesion of the right hepatic duct and placement of a transcistic drain, as well as a drain from the right hepatic duct through the Fateri papilla. Postoperative transdrainage cholangiography established the integrity of the bile ducts and the free passage of contrast to the duodenum. Intraoperative identification of only two structures entering the gallbladder during cholecystectomy-cystic duct and cystic artery-is mandatory.

Background: Laparoscopic cholecystectomy is associated with a high safety profile. This study seeks to quantify the incidence of blood transfusion in both the elective and emergency settings, examine related patient outcomes, and investigate selection criteria for pre-operative Group and Save (G&S) sampling. Methods: A prospective multi-centre observational study was conducted to investigate patients undergoing either elective or emergency laparoscopic cholecystectomy in the UK between January 2020 and May 2021. Multivariate logistical regression models were used to identify patient factors associated with the risk of transfusion and explore outcomes linked to pre-operative G&S sampling. Results: This study comprised 959 patients, with 631 (65.8%) undergoing elective cholecystectomy and 328 (34.2%) undergoing emergency surgery. The median age was 48 years (range: 35-59), with 724 (75.5%) of the patients being female. Only five patients (0.5%) required blood transfusions, receiving an average of three units, with the first unit administered approximately six hours post-operatively. Among these cases, three patients (60%) had underlying haematological conditions. In adjusted models, male gender was significantly associated with the need for a blood transfusion (OR 11.31, p = 0.013), while the presence of a pre-operative Group and Save sample did not demonstrate any positive impact on patient outcomes. Conclusions: The incidence of blood transfusion following laparoscopic cholecystectomy is very low. Male gender and haematological conditions may present as independent risk factors. Pre-operative G&S sampling did not yield any positive impact on patient outcomes and could be safely excluded in both elective and emergency cases, although certain population subsets will warrant further consideration.

Laparoscopic cholecystectomy (LC) remains one of the most commonly performed procedures in adult and paediatric populations. Despite the advances made in intraoperative biliary anatomy recognition, iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems. A series of methods have been proposed to prevent bile duct injury, among them the use of indocyanine green (ICG) fluorescence. The most commonly reported method of ICG injection is the intravenous administration, while literature is lacking studies investigating the direct intragallbladder ICG injection. This narrative mini-review aims to assess the potential applications, usefulness, and limitations of intragallbladder ICG fluorescence in LC. Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy, as well as special issues regarding its use. Literature search retrieved four prospective cohort studies, three case-control studies, and one case report. In the three case-control studies selected, intragallbladder near-infrared cholangiography (NIRC) was compared with standard LC under white light, with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography (IOC). In total, 133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC. Literature includes several reports of intragallbladder ICG administration, but a standardized technique has not been established yet. Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping, overwhelming limitations of IOC including intervention and radiation exposure, as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence. Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Laparoscopic cholecystectomy (LC) represents one of the most commonly performed routine abdominal surgeries. Nevertheless, besides bile duct injury, problems caused by lost gallstones represent a heavily underestimated and underreported possible late complication after LC.

Case report of a Clavien-Dindo IVb complication after supposedly straightforward LC and review of all published case reports on complications from lost gallstones from 2000-2022.

An 86-year-old patient developed a perihepatic abscess due to lost gallstones 6 months after LC. The patient had to undergo open surgery to successfully drain the abscess. Reactive pleural effusion needed additional drainage. Postoperative ICU stay was 13 days. The patient was finally discharged after 33 days on a geriatric remobilization ward and died 12 months later due to acute cardiac decompensation.

Intraabdominal abscess formation due to spilled gallstones may present years after LC as a late complication. Surgical management in order to completely evacuate the abscess and remove all spilled gallstones may be required, which could be associated with high morbidity and mortality, especially in elderly patients. Regarding the overt underreporting of gallstone spillage in case of postoperative gallstone-related complications, focus need be put on precise reporting of even apparently innocuous complications during LC.

Acute pancreatitis is the recurrent reason for gastrointestinal admission in a clinical urgent setting, it happens secondary to a wide array of pathologies out of which biliary disease stands as one of the most frequent causes for its presentation. Approximately 20% of pancreatitis are of moderate or severe severity. Currently, there is not a clear recommendation on timing for cholecystectomy, either early or delayed. CHISPA is a randomized controlled, parallel-group, superior clinical trial. An intention-to-treat analysis will be performed. It seeks to evaluate differences between patients taken to early cholecystectomy during hospital admission (72 hours after randomization) versus delayed cholecystectomy (30±5 days after randomization). The primary endpoint is major complications associated with laparoscopic cholecystectomy defined as a Clavien-Dindo score of over III/V during the first 90 days after the procedure. Secondary endpoints include recurrence of biliary disease, minor complications (Clavien-Dindo score below III/V), days of postoperative hospital stay, and length of stay in an intensive therapy unit postoperatively (if it applies). The CHISPA trial has been designed to demonstrate that delayed laparoscopic cholecystectomy reduces the rate of complications associated to an episode of severe biliary pancreatitis compared to early laparoscopic cholecystectomy.Trial registration number: NCT06113419.

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

Bile duct injuries during laparoscopic cholecystectomy can arise from misinterpretation of biliary anatomy, leading to dissection in improper areas. The integration of a deep learning framework into laparoscopic procedures offers the potential for real-time anatomical landmark recognition, ensuring accurate dissection. The objective of this study is to develop a deep learning framework that can precisely identify anatomical landmarks, including Rouviere's sulcus and the liver base of segment IV, and provide a guided dissection line during laparoscopic cholecystectomy.

We retrospectively collected 40 laparoscopic cholecystectomy videos and extracted 80 images form each video to establish the dataset. Three surgeons annotated the bounding boxes of anatomical landmarks on a total of 3200 images. The YOLOv7 model was trained to detect Rouviere's sulcus and the liver base of segment IV as anatomical landmarks. Additionally, the guided dissection line was generated between these two landmarks by the proposed algorithm. To evaluate the performance of the detection model, mean average precision (mAP), precision, and recall were calculated. Furthermore, the accuracy of the guided dissection line was evaluated by three surgeons. The performance of the detection model was compared to the scaled-YOLOv4 and YOLOv5 models. Finally, the proposed framework was deployed in the operating room for real-time detection and visualization.

The overall performance of the YOLOv7 model on validation set and testing set were 98.1 % and 91.3 %, respectively. Surgeons accepted the visualization of guide dissection line with a rate of 95.71 %. In the operating room, the well-trained model accurately identified the anatomical landmarks and generated the guided dissection line in real-time.

The proposed framework effectively identifies anatomical landmarks and generates a guided dissection line in real-time during laparoscopic cholecystectomy. This research underscores the potential of using deep learning models as computer-assisted tools in surgery, providing an assistant tool to accommodate with surgeons.

Indocyanine green (ICG) is an injectable fluorochrome that has recently gained popularity as a means of assisting intraoperative visualization during laparoscopic and robotic surgery. Many systematic reviews and meta-analyses have been published. We conducted a meta-review to synthesize the findings of these studies.

PubMed and Embase were searched to identify systematic reviews and meta-analyses coping with the uses of ICG in abdominal operations, including Metabolic Bariatric Surgery, Cholecystectomy, Colorectal, Esophageal, Gastric, Hepato-Pancreato-Biliary, Obstetrics and Gynecology (OG), Pediatric Surgery, Surgical Oncology, Urology, (abdominal) Vascular Surgery, Adrenal and Splenic Surgery, and Interdisciplinary tasks, until September 2023. We submitted the retrieved meta-analyses to qualitative analysis based on the AMSTAR 2 instrument.

We identified 116 studies, 41 systematic reviews (SRs) and 75 meta-analyses (MAs), spanning 2013-2023. The most thoroughly investigated (sub)specialties were Colorectal (6 SRs, 25 MAs), OG (9 SRs, 15 MAs), and HPB (4 SRs, 12 MAs). Interestingly, there was high heterogeneity regarding the administered ICG doses, routes, and timing. The use of ICG offered a clear benefit regarding anastomotic leak prevention, particularly after colorectal and esophageal surgery. There was no clear benefit regarding sentinel node detection after OG. According to the AMSTAR 2 tool, most meta-analyses ranked as "critically low" (34.7%) or "low" (58.7%) quality. There were only five meta-analyses (6.7%) that qualified as "moderate" quality, whereas there were no "high" quality reviews.

Regardless of the abundance of pertinent literature and reviews, surgeons should be cautious when interpreting their results on ICG use in abdominal surgery. Future reviews should focus on ensuring methodological vigor; establishing clear protocols of ICG dose, route of administration, and timing; and improving reporting quality. Other sources of data (e.g., registries) and novel methods of data analysis (e.g., machine learning) might also contribute to an enhanced role of ICG as a decision-making tool in surgery.

Evaluation of the cystic duct anatomy prior to bile duct or gallbladder surgery is important, to decrease the risk of bile duct injury. This study aimed to clarify the frequency of cystic duct variations and the relationship between them.

Data of 205 patients who underwent cholecystectomy after imaging at Sada Hospital, Japan, were analyzed. The Chi-square test was used to analyze the relationships among variations.

The lateral and posterior sides of the bile duct were the two most common insertion points (92 patients, 44.9%), and the middle height was the most common insertion height (135 patients, 65.9%). Clinically important variations (spiral courses, parallel courses, low insertions, and right hepatic duct draining) relating to the risk of bile duct injury were observed in 24 patients (11.7%). Regarding the relationship between the insertion sides and heights, we noticed that the posterior insertion frequently existed in low insertions (75.0%, P < 0.001) and did not exist in high insertions. In contrast, the anterior insertion coexisted with high and never low insertions. Spiral courses have two courses: anterior and posterior, and anterior ones were only found in high insertion cases.

The insertion point of the cystic duct and the spiral courses tended to be anterior or lateral superiorly and posterior inferiorly. Clinically significant variations in cystic duct insertions are common and surgeons should be cautious about these variations to avoid complications.

Bile duct injury is a major complication of laparoscopic cholecystectomy (LC). Indocyanine green near-infrared fluorescence cholangiography (ICG-NIFC) is a well-recognized technique who provides an intraoperative mapping of the biliary system.

All patients underwent urgent LC and randomly divided into two groups: in one group, only white light imaging was used and, in the ICG group, ICG was used. Due to the heterogeneity of our groups, a PSM was performed with a 1:1 PSM cohort.

The use of ICG clearly decreases the operation time (p value 0.002). The overall rate of intra- and post- operative complications was 4.17% and 15.8% respectively. Post-operative biliary duct injury trend decreases in ICG group and after the homogenization of the 2 cohorts, the intra- and post- operative complications (including vascular and biliary duct injury) results changed with a highest rate of complication in the cohort with no-ICG administration. The use of NIFC demonstrated a protective effect against intra- and post- operative complications and biliary duct injury (HR 0.037, p value 0.337 and HR 0.039, p value 0.647; HR 0.288; p value 0.05 and HR 0.635; p value 0.687, respectively).

The intra-operative use of NIFC showed a trend in the reduction of the rate of intra- and post-operative complications, the duration of surgery, and the length of hospital stay. ICG is a highly safe approach to urgent and emergency LC, as for elective LC, and could lead the surgeon to conduct the procedure more efficiently.

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed.

Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal.

Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique.

LC can be performed using different techniques, although the use of EBVS is highly recommended.