Single-Incision Laparoscopic Cholecystectomy Using a Set of Novel Needle Instruments.

BACKGROUND: Although the technique of single-incision laparoscopic cholecystectomy (SILC) has improved remarkably, problems such as limited exposure and instrument collision persist. We describe a new SILC technique that uses a set of specially-designed needle instruments. METHODS: Fifty-six patients with benign gallbladder disease underwent SILC using the newly-designed needle assembly instruments (NAIs). The NAIs comprise an needle assembly exposing hook for operative field exposure and an needle assembly electrocoagulation hook for dissection. During the operation, the NAIs were assembled and disassembled before and after gallbladder removal within the abdominal cavity. The operative efficacy and postoperative complications of this procedure were evaluated. RESULTS: SILC was completed successfully in 52 cases, and four cases (7.14%) required an additional trocar. There were no conversions to open surgery. The mean operative time was 48.2 ± 21.8 min, and the mean operative bleeding volume was 10.5 ± 12.5 mL. Minor postoperative complications occurred in 3 cases, including 2 cases of localized fluid accumulation in the abdominal cavity and 1 case of pulmonary infection, and all of them recovered after conservative treatment. There was no occurrence of bile leak, abdominal bleeding, bile duct injury and incisional hernia. The medical cost of each case was saved by approximately $200. The abdominal scars produced by the needle instruments were negligible. CONCLUSION: NAIs can make SILC safer, more convenient, and less expensive.

Localized gallbladder perforation: a systematic review of treatment and prognosis.

BACKGROUND: The optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. The aim of this systematic review was to identify factors associated with improved patient outcomes. METHODS: Systematic review of studies that described the management of Neimeier type II perforation, reported complications of the first intervention, necessity of added interventions, resolution of the pathology, and days of hospital stay were included. The search strategy was conducted in EMBASE, Mayo Journals, MEDLINE, SCOPUS, and Web of Science (December 2020) RESULTS: A total of 122 patients (53% male) from case reports, series, and cohorts were included for analysis. In total 56 (46%) and 44 (36%)patients were treated with open and laparoscopic cholecystectomy respectively. Overall risk of bias was moderate. The need for another intervention was higher in the laparoscopic group (5 vs 17, p=<0.001) as well as prevalence of complications (4 vs 16, p=<0.001), but lower for days of hospital stay (median days 5. vs 15, p = 0.008) against open cholecystectomy. Preoperative percutaneous catheter drainage did not influence outcome. CONCLUSION: Open cholecystectomy has a lower need for further surgical procedures and postoperative complications, but a longer hospital stay. These outcomes did not vary with preoperative percutaneous drainage. The effect of timing of cholecystectomy did not influence the outcomes.

Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis.

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

Retrohepatic Gallbladder Masquerading as Hydatid Cyst in a Patient with Right Liver Agenesis.

Agenesis of the right liver is a rare congenital anomaly which can be associated with an ectopic gallbladder. Hereby, it is presented the case of a 39-year-old man investigated for right upper quadrant abdominal pain and diagnosed at computed tomography with a cystic liver mass initially considered as hydatid cyst. At laparotomy, it was discovered agenesis of the right liver and the presumed hydatid cyst was a retrohepatic gallbladder with lithiasis. Cholecystectomy was performed with an uneventful outcome. Reassessment of the computed tomography images by an experienced radiologist confirmed the intraoperative diagnosis. Although agenesis of the right liver with retrohepatic gallbladder is an exceptional appearance, surgeons should be aware of this anomaly because it can raise challenging issues of diagnosis and surgical planning during cholecystectomy.

Safety of single-incision robotic cholecystectomy for benign gallbladder disease: a systematic review.

BACKGROUND: Multiport laparoscopic cholecystectomy (MLC) is the gold standard technique for cholecystectomy. In order to reduce postoperative pain and improve cosmetic results, the application of the single-incision laparoscopic cholecystectomy (SILC) technique was introduced, leading surgeons to face important challenges. Robotic technology has been proposed to overcome some of these limitations. The purpose of this review is to assess the safety of single-incision robotic cholecystectomy (SIRC) for benign disease. METHODS: An Embase and Pubmed literature search was performed in February 2017. Randomized controlled trial and prospective observational studies were selected and assessed using PRISMA recommendations. Primary outcome was overall postoperative complication rate. Secondary outcomes were postoperative bile leak rate, total conversion rate, operative time, wound complication rate, postoperative hospital stay, and port site hernia rate. The outcomes were analyzed in Forest plots based on fixed and random effects model. Heterogeneity was assessed using the I2 statistic. RESULTS: A total of 13 studies provided data about 1010 patients who underwent to SIRC for benign disease of gallbladder. Overall postoperative complications rate was 11.6% but only 4/1010 (0.4%) patients required further surgery. A postoperative bile leak was reported in 3/950 patients (0.3%). Conversion occurred in 4.2% of patients. Mean operative time was 86.7 min including an average of 42 min should be added as for robotic console time. Wound complications occurred in 3.7% of patients. Median postoperative hospital stay was 1 day. Port site hernia at the latest follow-up available was reported in 5.2% of patients. CONCLUSIONS: The use of the Da Vinci robot in single-port cholecystectomy seems to have similar results in terms of incidence and grade of complications compared to standard laparoscopy. In addition, it seems affected by the same limitations of single-port surgery, consisting of an increased operative time and incidence of port site hernia.

A randomized controlled trial for evaluation of lower abdominal laparoscopic cholecystectomy.

BACKGROUND: To improve minimally invasive outcomes, we designed a new procedure, lower abdominal laparoscopic cholecystectomy (LALC). This study was conducted to evaluate the effects of LALC versus classical (CLC) and single-incision (SILC) laparoscopic cholecystectomy on reducing systemic acute inflammatory response, improving cosmesis, and postoperative pain relief. MATERIAL AND METHODS: Beginning from July 2014, 105 patients meeting the inclusion criteria were randomly assigned to three groups: LALC, CLC, and SILC. The primary endpoint was the determination of systemic inflammatory response to the surgery. Other outcome measures included cosmesis, postoperative pain, and perioperative indices. RESULTS: Each of the three groups consisted of 35 patients. The duration of the operation was significantly longer in the SILC group (p= .005). The rates of adverse events were similar. Changes in interleukin-6 (p = .001) and tumor-necrosis factor-α (p = .016) measured before and after surgery differed significantly; patients who underwent LALC had the smallest change in inflammatory response. Cosmesis scores at one (p = .002) and 12 (p = .004) weeks after surgery favored LALC and SILC. Significant differences in pain scores at four (p = .011) and 12 h (p = .024) postoperatively were also observed. CONCLUSIONS: In selected patients, LALC shows more advantages in terms of lower systemic inflammatory response, improved cosmesis, and a favorable postoperative pain profile when compared with CLC and SILC.

Combination of etoricoxib and low-pressure pneumoperitoneum versus standard treatment for the management of pain after laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Postoperative pain is one of the significant problems in laparoscopic surgery, especially during the first 6-12 h. This randomized controlled trial aimed to investigate the effect of combined preemptive etoricoxib 120 mg and low-pressure pneumoperitoneum for the management of pain after laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: One hundred and twenty patients aged 18-75 with American Society of Anesthesiologists class I-II who were candidates for elective LC were recruited into the study. The patients were randomly divided into two groups, by 'block of four' randomization. The treatment group received preemptive etoricoxib 120 mg and intraabdominal pressure of 7 mmHg, and the control group received placebo and intraabdominal pressure of 14 mmHg. The postoperative pain score at rest was recorded utilizing a numeric rating scale at 1, 2, 6, 10, 14, 18, 22, and 24 h. Pain on movement/ambulation (cough) was also recorded at 6, 10, 14, 18, 22, and 24 h. RESULTS: There were no significant differences in the baseline characteristics of the two groups. The pain scores of the treatment versus control group of abdominal pain and incisional pain were significant on movement. Abdominal pain scores of the treatment group were decreased 0.98 when compared with the control group (p = 0.017), and incisional pain scores were also decreased 0.99 (p = 0.001). The incidences of postoperative shoulder/back pain were statistically significant: 41.8 % vs. 66.7 % in the treatment and control group, respectively (p = 0.009). The postoperative hospital stay in the treatment group and control group was: 1 day = 96.4 and 75.0 %, >1 day = 3.6 and 25.0 %, respectively (p = 0.001). CONCLUSIONS: A combination of preemptive etoricoxib and low-pressure pneumoperitoneum had significant effects in decreasing overall pain and the incidence of shoulder/back pain after LC and also shortened the hospital stay. CLINICAL TRIALS REGISTRATION NUMBER: TCTR20140213001.

Cystic duct with no visible signal on magnetic resonance cholangiography is associated with laparoscopic difficulties: an analysis of 695 cases.

BACKGROUND/AIMS: We investigated the association between the magnetic resonance cholangiography (MRC) results and surgical difficulties and bile duct injuries during laparoscopic cholecystectomy (LC). METHODS: MRC was performed on 695 consecutive patients before LC. We divided the patients into two groups (visible cystic duct group and "no signal" cystic duct on MRC group) and compared them with regard to the length of the operation, conversion rate to open cholecystectomy (OC) and rate of bile duct injury. RESULTS: The "no signal" cystic duct on MRC group had a longer operation and higher rate of conversion to OC compared with the visible cystic duct group. However, there was no statistically significant difference in the occurrence rate of bile duct injury between the two groups. CONCLUSIONS: The "no signal" cystic duct on MRC group was associated with laparoscopic difficulties, but not with an increased rate of biliary injury. When a visible cystic duct is not observed on MRC an early conversion to open surgery may avoid a bile duct injury during LC.

Cholecystocolonic fistula.

Cholecystoenteric fistulas are a complication of biliary disease, having an estimated incidence in the range of 0.1 - 0.5 percent. Roughly 8-27 percent of these are of the cholecystocolonic type,1 occurring most commonly at the hepatic flexure. An 82-year-old male presented to our tertiary hospital emergency department and was diagnosed with a cholecystocolonic fistula (CCF) by CT imaging. Surgical evaluation confirmed the CT diagnosis with subsequent removal of the fistula and gallbladder, which was curative.

[Analysis of complications and clinical and pathologic factors in relation to the laparoscopic cholecystectomy]. / Analýza komplikací a klinicko-patologických faktoru ve vztahu k laparoskopické cholecystektomii.

INTRODUCTION: Laparoscopic cholecystectomy (LCHCE) is connected with a different spectrum of postoperative complications than classic cholecystectomy. The aim of this study was to analyse the complications and define their relation to some chosen clinical and pathological factors and their incidence. MATERIAL AND METHODS: We included 1014 patients that were operated (laparoscopic or converted cholecystectomy) at the Department of Surgery, University Hospital in Pilsen between January 1st 2008 and December 31st 2011. All included patients were at least one year after cholecystectomy in the time of the realization of this study therefore we could analyse late complications. The group of patients included 351 men (34.6%) and 663 women (65.4%). The median age was 57 years (range: 8-87 years). We evaluated the following clinical and pathological factors: a histopathological diagnosis, early surgical and internal complications (with manifestation within 30 days after cholecystectomy) classified by the Clavien-Dindo score, incisional hernia as a late complication, conversion, perforation of the gallbladder wall, the duration of hospital stay, the age of patients and the use of drain. The results of the study were calculated with use of statistical tests: the test of population probability, the two-sample t-test, the ODDS ratio) and then were compared with published literature data. RESULTS: Surgical and internal complications occurred in 138 patients (13.6%) within 30 postoperative days. The most common complication was connected with the wound - 92 patients (9.1%), then a hematoma in the gallbladder bed - 16 patients (1.6%) and a biliary leak - 16 patients (1,6%). The bile duct injury which needed a reoperation affected 3 patients (0.3%). The laparoscopic operation had to be converted in 77 cases (7.6%). Incisional hernia after the placing of trocars or in the scar after the laparotomy (in the case of conversion) occurred in 32 patients (3.16%) during one year after the cholecystectomy. The influence of the age of patients on the incidence and the spectrum of postoperative complications were proved as statistically significant. Postoperative complications were more common in the case of male gender. We found a correlation between the diagnosis and postoperative complications. Men with solitary cholecystolithiasis had more common incidence of hematoma in the gallbladder bed. A biliary leak occurred three times more often after the procedures with a gallbladder wall perforation. Three of four bile duct injuries occurred during the non-converted laparoscopic cholecystectomies. CONCLUSION: Our study proved the influence of the age of patients, the histopathological diagnosis, conversion and the perforation of gallbladder wall on the incidence of postoperative complications after laparoscopic cholecystectomy. The incidence of bile duct injury, which is the most serious complication, in our group of patients is comparable with published literature.

Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis.

Laparoscopic cholecystectomy (LC) is the established gold standard treatment for benign gallbladder diseases. However, robotic cholecystectomy is still controversial. Therefore, we aimed to compare intraoperative and postoperative outcomes in LC and robotic-assisted cholecystectomy (RAC) in patients with nonmalignant gallbladder conditions. PubMed, Scopus, Cochrane Library, and Web of Science were systematically searched for studies comparing RAC to LC in patients with benign gallbladder disease. Only randomized trials and non-randomized studies with propensity score matching were included. Mean differences (MDs) were computed for continuous outcomes and odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.2.3. A total of 13 studies comprising 22,440 patients were included, of whom 10,758 patients (47.94%) underwent RAC. The mean age was 48.5 years and 65.2% were female. Compared with LC, RAC significantly increased operative time (MD 12.59 min; 95% CI 5.62-19.55; p < 0.01; I2 = 79%). However, there were no significant differences between the groups in hospitalization time (MD -0.18 days; 95% CI - 0.43-0.07; p = 0.07; I2 = 89%), occurrence of intraoperative complications (OR 0.66; 95% CI 0.38-1.15; p = 0.14; I2 = 35%) and bile duct injury (OR 0.99; 95% CI 0.64, 1.55; p = 0.97; I2 = 0%). RAC was associated with an increase in operative time compared with LC without increasing hospitalization time or the incidence of intraoperative complications. These findings suggest that RAC is a safe approach to benign gallbladder disease.

Gallbladder herniation into the lesser sac through the foramen of Winslow: report of a case.

We report a case of gallbladder hernia into the lesser sac through the foramen of Winslow. The patient was a 90-year-old woman, admitted to hospital with obstructive jaundice. Computed tomography (CT) showed a left-deviated and remarkably enlarged gallbladder dragging the liver, and a dilated intrahepatic bile duct. The deviated gallbladder was thought to compress the common bile duct, causing the obstruction. Laparoscopic examination revealed gallbladder herniation into the lesser sac without a floating gallbladder; thus, we performed laparoscopic cholecystectomy. Herniation of the gallbladder is the rarest of all internal hernias and most reported cases have involved a floating gallbladder. The case we report here is therefore considered especially unusual.

Single-incision laparoscopic cholecystectomy: a new retraction technique.

BACKGROUND: Laparo-endoscopic single site cholecystectomy receives great interest from the surgical community. It has potential for reducing postoperative pain, length of hospital stay and improving cosmesis. Minimally invasive surgeons have been forced to develop techniques for providing adequate retraction of the gallbladder. Herein, we describe a new retraction technique to improve the dissection of Calot's triangle. SURGICAL TECHNIQUE: Twelve patients underwent laparo-endoscopic single site laparoscopic cholecystectomy using this retraction technique. An intra-umbilical skin incision was made by pulling out the umbilicus. A SILS port was placed through an open approach. We inserted a 10-mm 30 degrees camera through the SILS port without using any trocar. One suture was knotted in the middle of the gallbladder. Gallbladder retraction was achieved by the use of an EndoClose needle that was inserted into abdominal cavity at the subcostal border. The floppy knot was held by the notched end of the EndoClose needle. This device provided retraction of the gallbladder in every direction. CONCLUSIONS: Adequate retraction greatly simplifies laparo-endoscopic single site cholecystectomy. New retraction techniques will enable wider use of this novel minimally invasive approach. Further work is needed to investigate the advantages of this new technique.

Single-Incision Laparoscopic Cholecystectomy Versus Standard Multiport Approach for Gallbladder Disease in Children: A Systematic Review and Meta-Analysis.

Aim: To evaluate comparative outcomes of single-incision laparoscopic cholecystectomy (SILC) and standard multiport laparoscopic cholecystectomy (SLC) in the management of children with various hematological or biliary disorders. Methods: A comprehensive systematic review of literature studies with subsequent meta-analysis of outcomes was conducted in line with preferred reporting items for systematic reviews and meta-analyses statement standards. Operative time, length of hospital stay, and postoperation complications were extracted. Results: Seven researches reporting a total number of 479 patients who underwent SILC (n = 235) or SLC (n = 244) were included. There was no difference between SILC and SLC groups in operative time (mean difference (MD) 15.14, 95% confidence interval [CI] [10.50-19.79], P = .07) and length of hospital stay (MD 0.83, 95% CI [-2.41 to 4.06], P = .62). Postoperation complications and the cost also seemed similar. Conclusions: SILC and SLC seem to have comparable effect and safety in children. Future high-quality randomized controlled trials with adequate sample sizes and long-term follow-up are required to provide stronger evidence in favor of the intervention.

True left-sided gallbladder with a portal anomaly: report of a case.

A 65-year-old female who presented with back pain was diagnosed to have the presence of biliary sludge in the gallbladder. Computed tomography showed that the round ligament connected to the left portal umbilical portion was in the normal anatomical position. However, the gallbladder was located to the left of the middle hepatic vein and the round ligament, attached to the left lateral segment of the liver. The right posterior portal vein diverged alone from the main portal vein, and there was a long stem from the right anterior and left portal veins. Laparoscopic cholecystectomy confirmed the abnormal location of the gallbladder. Most reported cases of left-sided gallbladder are caused by a right-sided round ligament, which is called a "false" left-sided gallbladder. A case of left-sided gallbladder with a normal left-sided round ligament, which is designated as a case of "true" left-sided gallbladder, is extremely rare.

Laparoscopic cholecystectomy in cirrhotics.

BACKGROUND AND OBJECTIVES: Due to the concern of risk of intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered a contraindication for laparoscopic cholecystectomy (LC). This article intends to review the literature and underline the various approaches to dealing with this technically challenging procedure. METHODS: A Medline search of major articles in the English literature on LC in cirrhotic patients over a 16-y period from 1994 to 2011 was reviewed and the findings analyzed. A total of 1310 cases were identified. RESULTS: Most the patients who underwent LC were in Child-Pugh class A, followed by Child-Pugh classes B and C, respectively. The overall conversion rate was 4.58%, and morbidity was 17% and mortality 0.45%. Among the patients who died, most were in Child-Pugh class C, with a small number in classes B and A. The cause of death included, postoperative bleeding, liver failure, sepsis, duodenal perforation, and myocardial infarction. A meta-analysis of 400 patients in the literature, comparing outcomes of patients undergoing LC with and without cirrhosis, revealed higher conversion rate, longer operative time, higher bleeding complications, and overall increased morbidity in patients with cirrhosis. Safe LC was facilitated by measures that included the use of ultrasonic shears and other hemostatic measures and using subtotal cholecystectomy in patients with difficult hilum and gallbladder bed. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in cirrhotic patients, within Child-Pugh classes A and B, with acceptable morbidity and conversion rate.

[The porcelain gallbladder-laparoscopic approach]. / Vezicula de portelan--abord laparoscopic.

A long time porcelain gallbladder was considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer. From 12,000 patients underwent cholecystectomy in First Surgical Clinic of Iasi, 5 (0.04%) patients had porcelain gallbladder. All patients underwent ultrasound examen. Patients with porcelain gallbladder were classified as Type I to II according to preoperative ultrasound findings: three cases with porcelain gallbladder type I and two cases with porcelain gallbladder type II (in one case we found associated gallbladder carcinoma). We describe a three cases with porcelain gallbladder type I (complete calcification of gallbladder wall) treated by laparoscopic approach. Laparoscopic cholecystectomy was difficult because of adhesions and problems with grasping the thick gallbladder wall, but the postoperative course was uneventful. The histopathologic result of the specimen established the diagnosis of porcelain gallbladder type I and no cancer in the calcified wall of the gallbladder. We conclude based on cases presented and the literature review, although there is a high conversion rate, that patients with a type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.