Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures.

BACKGROUND: The critical view of safety (CVS) is poorly adopted in surgical practices, although it is recommended ubiquitously to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aimed to investigate whether performing a short intraoperative time-out can improve CVS implementation. STUDY DESIGN: In this before vs after study, surgeons performing LCs at an academic center were invited to use a 5-second long time-out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LC performed in the year before vs the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by 2 independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared. RESULTS: Three hundred and forty-three of 381 LC performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9% vs 44.1% before vs after the 5-second rule, respectively; p < 0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2% vs 15.7%; p = 0.04), median time (hours:minutes:seconds) to clip the cystic duct or artery (00:17:26; interquartile range 00:11:48 to 00:28:35 vs 00:23:12; interquartile range 00:14:29 to 00:31:45 duration; p = 0.007), and the rate of postoperative CVS reporting (1.3% vs 28.8%; p < 0.001). Postoperative morbidity was comparable (1.8% vs 2.3%; p = 0.68). CONCLUSIONS: Performing a short intraoperative time-out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.

Colecistectomía videolaparoscópica en el Hospital Militar Docente Dr. Mario Muñoz Monroy, Matanzas, 2014-2017 / Video laparoscopic cholecistectomy in the Military Hospital of Matanzas. 2014-2017

RESUMEN Introducción: en enero de 2000, comenzó la cirugía videolaparoscópica en el Hospital Militar Docente Dr. Mario Muñoz Monroy, de la ciudad de Matanzas. El equipo quirúrgico, en esa época, lo constituían cirujanos con varios años de experiencia y con una sólida formación en cirugía convencional. También poseían habilidades demostradas en la realización de colecistectomía a cielo abierto. A partir de 2011, una nueva generación de cirujanos desarrolló la cirugía mínimamente invasiva, con poca experiencia en cirugía a cielo abierto. Por lo tanto, se presentó la contradicción de que cada vez menos cirujanos tenían la experiencia técnica que requieren los casos más difíciles. Objetivo: determinar la seguridad en la realización de la colecistectomía laparoscópica. Materiales y métodos: Investigación observacional, descriptiva y retrospectiva de los pacientes intervenidos de afecciones biliares benignas, por la técnica de colecistectomía laparoscópica, entre enero de 2014 y diciembre de 2017. Resultados: fueron colecistectomizados 2 016 pacientes. De ellos, 1 759 (87 %) correspondieron al sexo femenino, y 257 (13 %) al masculino. Comorbilidades presentes en el 46,3 %. Cirugías: electivas, 1 801; urgentes, 215. Eventos adversos, 38 (1,88 %). Conversiones, 28 (1,3 %). Mortalidad operatoria, 5 (0,24 %). Conclusiones: resultan seguras las colecistectomías laparoscópicas por el bajo índice de eventos adversos, conversiones y mortalidad operatoria (AU).

ABSTRACT Introduction: video laparoscopic surgery began in January 2000, at the Dr. Mario Muñoz Monroy Military Hospital. The surgical team, at that time, were surgeons with years of experience and a solid training in conventional surgery. They also had demonstrated skills in performing open cholecystectomy. Starting in 2011, a new generation of surgeons developed minimally invasive surgery, with little experience in open surgery. Therefore, it arose the paradox that fewer and fewer surgeons had the technical experience required in the most difficult cases. Objective: to determine the safety in performing laparoscopic cholecystectomy. Materials and methods: retrospective, descriptive and observational research of the patients who underwent surgeries of benign biliary conditions, by the technique of laparoscopic cholecystectomy in the period January 2014- December 2017. Results: 1759 patients were cholecystectomized. 87.25% were female ones and 257 (13%) were male: Comorbidities were present in 46.3%. 1 801 were elective surgeries; emergency surgeries were 215. There were 38 (1.88%) adverse events and 28 (1.3%) conversions. The operatory mortality was 5 (0.24%). Conclusions: laparoscopic cholecystectomy are safe because of the low index of adverse events, conversion and operatory mortality (AU).

A Computer Vision Platform to Automatically Locate Critical Events in Surgical Videos: Documenting Safety in Laparoscopic Cholecystectomy.

OBJECTIVE: The aim of this study was to develop a computer vision platform to automatically locate critical events in surgical videos and provide short video clips documenting the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). BACKGROUND: Intraoperative events are typically documented through operator-dictated reports that do not always translate the operative reality. Surgical videos provide complete information on surgical procedures, but the burden associated with storing and manually analyzing full-length videos has so far limited their effective use. METHODS: A computer vision platform named EndoDigest was developed and used to analyze LC videos. The mean absolute error (MAE) of the platform in automatically locating the manually annotated time of the cystic duct division in full-length videos was assessed. The relevance of the automatically extracted short video clips was evaluated by calculating the percentage of video clips in which the CVS was assessable by surgeons. RESULTS: A total of 155 LC videos were analyzed: 55 of these videos were used to develop EndoDigest, whereas the remaining 100 were used to test it. The time of the cystic duct division was automatically located with a MAE of 62.8 ±â€Š130.4 seconds (1.95% of full-length video duration). CVS was assessable in 91% of the 2.5 minutes long video clips automatically extracted from the considered test procedures. CONCLUSIONS: Deep learning models for workflow analysis can be used to reliably locate critical events in surgical videos and document CVS in LC. Further studies are needed to assess the clinical impact of surgical data science solutions for safer laparoscopic cholecystectomy.

Learning to teach: A novel method for assessing surgical trainees' teaching and operative knowledge.

BACKGROUND: The purpose of this study was to investigate the feasibility of a simulated teaching activity as an assessment of surgical knowledge and teaching competencies. METHODS: In this prospective observational study, 15 residents and 1 fellow in the Department of Surgery watched three video clips of laparoscopic cholecystectomies and provided feedback to a participant learner. Qualitative and statistical analysis identified differences in surgical knowledge and teaching strategies. RESULTS: As compared to senior trainees, junior trainees were more likely to speculate on the learner's actions (p = 0.033), identify which actions looked correct (p = 0.028), and speculate more on the learner's thoughts (p = 0.02). Senior trainees noted case difficulty more frequently (p = 0.028), identified more actions that looked incorrect (p = 0.004), and speculated more about the learner's emotions (p = 0.033). CONCLUSIONS: A simulated teaching scenario successfully assessed operative and teaching competencies, suggesting a novel assessment method.

Is Specialisation Needed in Laparoscopic Cholecystectomy? A Retrospective Cohort Study of 5122 Patients.

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

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis.

The safety and feasibility of early laparoscopic cholecystectomy (LC) for acute cholecystitis with mild pancreatitis were explored. A total of 973 patients with acute pancreatitis, including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department. And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study, of which 328 patients underwent LC during the same-admission (early LC group), and 98 patients underwent LC a period of time after conservative treatment (delayed LC group). Clinical characteristics, operative findings and complications were recorded and followed up. The two groups were comparable in age, gender, the grade of American Society of Anesthesiologist (ASA), biochemical findings and Balthazar computer tomography (CT) rating (P>0.05). The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group (5.83±1.62 vs. 41.36±8.44 days; 11.38±2.43 vs. 16.49±3.48 days, P<0.01). There was no significant difference in the average operation time between the two groups. No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group (P<0.01). There was no significant difference in conversion rate (3.85 vs. 5.10%, P=0.41) and surgical complication rate (3.95 vs. 4.08%, P=0.95) between early LC group and delayed LC group. During the postoperative follow-up period of 375 cases, biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group (P=0.37). The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.

Comparison of surgeon gaze behaviour against objective skill assessment in laparoscopic cholecystectomy-a prospective cohort study.

BACKGROUND: Eye tracking technology may provide the basis of a novel, objective technical skill assessment in surgery. Past research has showed differences in the gaze patterns between expert and novice surgeons. The aim of this study was to investigate the relationship between gaze behaviors and technical skill during laparoscopic cholecystectomy as determined by objective assessment scores. METHODS: Gaze behaviors of surgeons performing laparoscopic cholecystectomies were mapped using wearable eye tracking apparatus. Two impartial surgeons retrospectively analyzed video footage of the procedure to perform Objective Structured Assessment of Technical Skill (OSATS) assessments. Primary endpoints were correlation between gaze behaviours (dwell time (%) and fixation frequency (count/s)) and OSATS scores. Dwell time was defined as the percentage of time spent fixating on particular visual areas of interest (AOI). Pearson's correlation coefficient was used to estimate the relationship between primary endpoints and AOIs. Statistical significance was set at p < 0.05. RESULTS: 13 procedures were analyzed. Throughout all operative segments, a negative correlation was present between operating theatre dwell time and OSATS scores (p < 0.05). During dissection of Calot's triangle, there was a strong positive correlation between laparoscopic screen dwell time and OSATS scoring [r = 0.655, p < 0.05]. Scrub nurse dwell time during dissection of Calot's triangle showed a strong negative correlation with OSATS scoring [r = -0.619, p < 0.05]. During dissection of gallbladder fossa, operating theatre fixation frequency negatively correlated against OSATS scores [r = -0.566, p < 0.05]. CONCLUSION: The results suggest a greater focus on significant visual stimuli alongside a lack of attention to non-essential stimuli during critical stages of the operative period is associated with greater technical skill. This aids the validation of eye tracking as an adjunct high-stakes technical skill assessment.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy.

BACKGROUND: BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. METHODS: Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. RESULTS: Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. CONCLUSIONS: These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Association of Video Completed by Audio in Laparoscopic Cholecystectomy With Improvements in Operative Reporting.

Importance: All events that transpire during laparoscopic cholecystectomy (LC) cannot be adequately reproduced in the operative note. Video recording is already known to add important information regarding this operation. Objective: It is hypothesized that additional audio recordings can provide an even better procedural understanding by capturing the surgeons' considerations. Design, Setting, and Participants: The Simultaneous Video and Audio Recording of Laparoscopic Cholecystectomy Procedures (SONAR) trial is a multicenter prospective observational trial conducted in the Netherlands in which operators were requested to dictate essential steps of LC. Elective LCs of patients 18 years and older were eligible for inclusion. Data collection occurred from September 18, 2018, to November 13, 2018. Main Outcomes and Measures: Adequacy rates for video recordings and operative note were compared. Adequacy was defined as the competent depiction of a surgical step and expressed as the number of adequate steps divided by the total applicable steps for all cases. In case of discrepancies, in which a step was adequately observed in the video recording but inadequately reported in the operative note, an expert panel analyzed the added value of the audio recording to resolve the discrepancy. Results: A total of 79 patients (49 women [62.0%]; mean [SD] age, 54.3 [15.9] years) were included. Video recordings resulted in higher adequacy for the inspection of the gallbladder (note, 39 of 79 cases [49.4%] vs video, 79 of 79 cases [100%]; P < .001), the inspection of the liver condition (note, 17 of 79 [21.5%] vs video, 78 of 79 cases [98.7%]; P < .001), and the circumferential dissection of the cystic duct and the cystic artery (note, 25 of 77 [32.5%] vs video, 62 of 77 [80.5%]; P < .001). The total adequacy was higher for the video recordings (note, 849 of 1089 observations [78.0%] vs video, 1005 of 1089 observations [92.3%]; P < .001). In the cases of discrepancies between video and note, additional audio recordings lowered discrepancy rates for the inspection of the gallbladder (without audio, 40 of 79 cases [50.6%] vs with audio, 17 of 79 cases [21.5%]; P < .001), the inspection of the liver condition (without audio, 61 of 79 [77.2%] vs with audio, 37 of 79 [46.8%]; P < .001), the circumferential dissection of the cystic duct and the cystic artery (without audio, 43 of 77 cases [55.8%] vs with audio, 17 of 77 cases [22.1%]; P < .001), and similarly for the removal of the first accessory trocar (without audio, 27 of 79 [34.2%] vs with audio, 16 of 79 [20.3%]; P = .02), the second accessory trocar (without audio, 24 of 79 [30.4%] vs with audio, 11 of 79 [13.9%]; P < .001), and the third accessory trocar (without audio, 27 of 79 [34.2%] vs with audio, 14 of 79 [17.7%]; P < .001). The total discrepancy was lower with audio adjustment (without audio, 254 of 1089 observations [23.3%] vs with audio, 128 of 1089 observations [11.8%]; P < .001). Conclusions and Relevance: Audio recording during LC significantly improves the adequacy of depicting essential surgical steps and exhibits lower discrepancies between video and operative note.

Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis.

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

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide.

BACKGROUND: Although laparoscopic inguinal hernia repair was described about 30 years ago and advantages of the technique have been demonstrated, the utilization of this approach has not been what we would expect. Some reasons may be the need for surgeons to understand the posterior anatomy of the groin from a new vantage point, as well as to acquire advanced laparoscopic skills. Recently, however, the introduction of a robotic approach has dramatically increased the adoption of minimally invasive techniques for inguinal hernia repair. METHODS: Important recent contributions to this evolution have been the establishment of a new concept known as the critical view of the Myopectineal Orifice (MPO) and the description of a new way of understanding the posterior view of the antomy of the groin (inverted Y and the five triangles). In this paper, we describe 10 rules for a safe MIS inguinal hernia repair (TAPP, TEP, ETEP, RTAPP) that combines these two new concepts in a unique way. CONCLUSIONS: As the critical view of safety has made laparoscopic cholecystectomy safer, we feel that following our ten rules based on understanding the anatomy of the posterior groin as defined by zones and essential triangles and the technical steps to achieve the critical view of the MPO will foster the goal of safe MIS hernia repair, no matter which minimally invasive technique is employed.

Improving the day case rate for laparoscopic cholecystectomy via introduction of a dedicated clinical pathway.

Day case laparoscopic cholecystectomy is a safe and economical procedure. However, successful discharge on the same day of the procedure has been difficult to achieve at our institution. This study introduced a standardised anaesthetic pathway aiming to increase same day discharges. This led to an overall increase in same day discharges from 42.0% to 54.1%. When the pathway was fully followed, 71% of patients were discharged on the same day. When the pathway was not followed at all, the same day discharge rate was 0%. Our study successfully demonstrates that small enhancements to perioperative care can accelerate patient recovery and improve same day discharges.

Improving attainment of the critical view of safety during laparoscopic cholecystectomy.

INTRODUCTION: We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum. METHODS: All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum. RESULTS: Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017). CONCLUSION: A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the Critical View of Safety during LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety.

ERAS protocol for pediatric laparoscopic cholecystectomy promotes safe and early discharge.

PURPOSE: Elective laparoscopic cholecystectomy (LC) pediatric patients in our institution have historically been admitted for an overnight hospital stay (OHS). The purpose of this study was to implement an ERAS protocol for elective LC in pediatric patients to promote same-day discharge (SDD) while maintaining excellent outcomes. METHODS: An ERAS protocol for elective LC was implemented encompassing pre-, peri-, and postoperative management. A retrospective review of prospectively collected data from patients before (BI) and after implementation (AI) of the protocol was performed. RESULTS: A total of 250 patients (BI 105, AI 145) were included in the study. The AI group had significantly higher rate of SDD compared to BI (77.2% vs. 1.9%, p < <0.01) and significantly decreased opioid use (morphine equivalents mg/kg AI 0.36 vs. BI 0.46, p < <0.001). There were also no significant differences in the rate of total 30-day emergency department visits (BI 11.4% vs. AI 9.7%, p = 0.52) or surgery-related 30-day emergency department visits (BI 7.6% vs. AI 8.3%, p = 0.53). Factors that predisposed patients to an OHS after LC included higher ASA, later surgery start times, and longer operative times. CONCLUSIONS: The ERAS protocol significantly increased the rate of SDD after elective LC in pediatric patients without an associated increase in emergency department visits or readmissions. LEVEL OF EVIDENCE: III.

Quality and patient satisfaction after ambulatory laparoscopic management of non-severe and uncomplicated gallbladder pathology.

INTRODUCTION: Ambulatory laparoscopic cholecystectomy (ALC) reduces the use of hospital beds and benefits the patient by returning home sooner. Therefore, it is important to evaluate the degree of patient satisfaction. MATERIALS AND METHODS: A controlled clinical trial was designed to assess the efficacy, safety, and satisfaction of ALC, compared to the usual laparoscopic cholecystectomy (ULC). Efficacy and safety were evaluated based on; recovery of the oral route, spontaneous urination, gas channeling, presence of pain, nausea, vomiting, bleeding, pain, penrose expense. Satisfaction was explored through an adaptation of the SATISCORE questionnaire. RESULTS: We included 71 patients, 38 from the experimental group (ALC) and 33 from the control group (ULC). There was a higher proportion of women, average age at the fifth decade, and a similar distribution of comorbidities. In safety and efficacy, the results were similar. In the survey, the ALC group showed an 89.5% high degree of satisfaction. DISCUSSION: There was a good postoperative recovery in both groups as they reincorporated earlier, identified in a better satisfaction index referred by the patient. CONCLUSION: The ALC is as effective and safe as ULC, so it can be considered as the new "gold standard" for the surgical management of uncomplicated biliary pathology.

INTRODUCCIÓN: La colecistectomía laparoscópica ambulatoria (CLA) disminuye la utilización de camas y beneficia al paciente al no hospitalizarse, siendo importante evaluar su grado de satisfacción. MATERIAL Y MÉTODOS: Se diseñó un ensayo clínico controlado para eficacia, seguridad y satisfacción de CLA comparándola con colecistectomía laparoscópica habitual (CLH). Eficacia y seguridad se evaluaron en cuanto; recuperación de vía oral, micción espontánea, canalización de gases, dolor, nausea, vómito, sangrado, y gasto del penrose. La satisfacción a través de una adaptación del cuestionario SATISCORE. RESULTADOS: Se incluyeron 71 pacientes, 38 del grupo experimental (CLA) y 33 del control (CLH). En ambos hubo una mayor proporción de mujeres, edad promedio en la quinta década, y distribución de comorbilidades semejante. En seguridad y eficacia, los resultados fueron semejantes. En la encuesta el grupo de CLA manifestó 89.5% de alto grado de satisfacción. DISCUSIÓN: Hubo una buena recuperación en ambos grupos, con una reincorporaron más temprana y un mejor índice de satisfacción referido por el enfermo en el grupo experimental (CLA). CONCLUSIÓN: La CLA es tan efectiva y segura como la CLH, por lo que se puede considerar como el nuevo "Estándar de oro" para el manejo quirúrgico de la patología biliar no complicada.

Is Opioid-Free General Anesthesia More Superior for Postoperative Pain Versus Opioid General Anesthesia in Laparoscopic Cholecystectomy?

INTRODUCTION: Opioid-free anesthesia (OFA) is a new anesthesiological technique, where the giving of opioids (fentanyl) is avoided in the intra- and post-operative period. This leads to reduction in the opioid-related side effects and lower pain scores in the postoperative period. MATERIALS AND METHODS: In this randomized, single-blind clinical study, 60 patients scheduled for elective laparoscopic cholecystectomy were enrolled. Half of them (30 patients) received general balanced anesthesia with fentanyl (F group-FG), and the half received opioid-free general anesthesia (OFA group-OFAG). In the post-operative period, Visual Analogue Scale (VAS) scores were followed at rest and when coughing 1 hour, 4 hrs, 8 hrs, 12 and 24 hrs after surgery. Both groups were followed by opioid requirements in the postoperative period. RESULTS: In the postoperative period, patients in the fentanyl group (FG) have higher pain scores at rest and on coughing in all analyzed timeframes compared to patients from the OFA group, but statistically significant difference was approved 1 and 24 hours after surgery. In the OFA group 24 hours after surgery none of the patients reported pain at rest and when coughing number 7, 8, 9 and 10 according to the VAS pain score. The total opioid requirement in the postoperative period was significantly higher in the fentanyl group (FG) at rest and when coughing, compared to the OFA group. CONCLUSION: Opioid-free anesthesia as a part of multimodal analgesia and a new anesthesiology technique is a safe procedure, where opioid-related negative effects in patients undergoing elective laparoscopic cholecystectomy are avoided..

Reduced Port Laparoscopic Cholecystectomy: An Innovative, Cost-Effective Technique with Superior Cosmetic Outcomes.

INTRODUCTION: Patient demand for cosmetically superior surgical outcomes has driven minimally invasive technique development like single incision laparoscopic cholecystectomy (SILC). Implementation has been hindered by equipment factors, compromise of ergonomics, increased cost, and larger primary incision, leading to the associated risk of postoperative wound complications, incisional hernia, and fascial dehiscence. We present a method of reduced port laparoscopic cholecystectomy (RPLC), which utilises existing laparoscopic conventional equipment and an innovative MiniLap® grasper (Teleflex Incorporated, Wayne, Pennsylvania). The aim of the approach being enhanced cosmesis, cost equivalence with existing methods, and preservation of surgical ergonomics. MATERIALS AND METHODS: Twenty consecutive patients presenting to a single-surgeon practice with pathology requiring cholecystectomy and favourable body habitus were offered an RPLC procedure. Abdominal access was obtained via two laparoscopic working ports placed through a single incision within the umbilicus and with a 2.3mm port-less MiniLap® inserted via stab incision in the right upper quadrant utilised for retraction. Operative time, cost, cosmesis, postoperative pain, and patient demographics were compared with the standard four-port cholecystectomy. RESULTS: Twenty patients underwent RPLC with age ranging from 20 to 67 with a mean body mass index (BMI) of 31kg/m2. Mean operative time of 36.3 minutes was comparable to conventional multi-port laparoscopic cholecystectomy (LC). All operations were completed as RPLC, and no conversion to conventional four-port laparoscopic cholecystectomy was required. Gall bladder retraction with Teleflex grasper and an innovative swirling technique provides adequate exposure of the hepato-cystic triangle. Patient response regarding cosmetic outcome of the procedure was overwhelmingly positive. A single complication of the RPLC technique was documented-a superficial umbilical site wound infection, which was treated with oral antibiotics. Instrumental cost of the RPLC was $80 (AUD) greater than standard 4LP due to reduced port number but higher MiniLap® cost. CONCLUSION: The RPLC method utilises an ergonomically attractive technique with outcomes and a safety profile equal to the standard multi-port LC whilst minimizing the complications and prohibitive economic penalties of traditional SILC. A well-designed prospective randomised trial can provide more insight into the pros and cons of this innovative technique.

Impact of Residents on Safety Outcomes in Laparoscopic Cholecystectomy.

INTRODUCTION: New training programs face quality concern by faculty who believe resident involvement in operative management may lead to poorer outcomes. This study aims to understand the impact of resident surgeons on outcomes in a specific common surgical procedure. METHODS: We obtained a retrospective review of 1216 laparoscopic cholecystectomy cases between June 2012 and June 2017 at a community teaching hospital. Data reviewed included patient demographics, operative time, length of stay, 30-day outcomes. An initial analysis comparing outcomes with/without resident participation was undertaken. A subset analysis comparing junior (PGY 1-2) and senior (PGY 3-5) groups was also performed. RESULTS: We found the resident group participated in higher-risk patient (ASA > 3, 47.5% vs 39.8%, p = 0.04 more acute disease (59.8% vs 37.5%, p < 0.0001) and emergent surgery (59.7% vs 37.5%, p < 0.0001). Resident involvement in severe cases was not a significant factor in the odds of morbidity, mortality, conversion rate or length of stay. Resident participation did increase the odds of having longer OR time (OR 12.54, 95% CI 7.74-17.34, p < 0.0001). CONCLUSIONS: Resident participation is associated with increased operative times but not complications. This study confirms resident participation in the operating room in difficult and challenging cases is safe.

Optimum timing of emergency cholecystectomy for acute cholecystitis in England: population-based cohort study.

BACKGROUND: Cholecystectomy on index admission for acute cholecystitis is associated with improved patient outcomes. The timing of intervention is mainly driven by service provision. This population-based cohort study aimed to evaluate timing of emergency cholecystectomy in England. METHODS: Data from all consecutive patients undergoing surgery for acute cholecystitis on index admission in England from 1997 to 2012 were captured from the Hospital Episodes Statistics database. Data were analysed based on whether patients underwent surgery 0-3 days, 4-7 days or ≥ 8 days from admission. Outcome measures were rate of post-operative biliary complications, conversion to open and length of stay. RESULTS: Forty-three thousand eight hundred and seventy patients underwent emergency cholecystectomy. 64.6% of patients underwent surgery between days 0 and 3 of admission, 24.3% between days 4-7 and 11.0% had surgery after day 8. Patients undergoing early surgery had significantly reduced rates of intra-operative laparoscopic conversion to open (0-3 days: 3.6%; 4-7 days: 4.0%; ≥ 8 days 4.7%, p = 0.001), post-operative ERCP (0-3 days: 1.1%; 4-7 days: 1.5%; ≥ 8 days 1.9%, p < 0.001) and bile duct injury (0-3 days: 0.6%; 4-7 days: 1.0%; ≥ 8 days 1.8%, p < 0.001). Early cholecystectomy was also associated with a shorter post-operative length of stay (LOS) [0-3 days group: median post-operative LOS 3 days (IQR: 1-6); 4-7 days group: 3 days (IQR 2-6); ≥ 8 days group: 4 days (IQR 2-9) (p < 0.001)]. High-volume centres undertook a significantly greater proportion of cholecystectomies within 3 days of presentation (high-volume: 67.3%; medium-volume: 64.8%; low-volume: 61.2%). In multivariate analysis greater time to surgery was independently associated with increased risk of post-operative ERCP and bile duct injury. CONCLUSIONS: Early cholecystectomy within 3 days of admission reduces intra-operative conversion, post-operative biliary complications and length of stay. Centres undertaking the greatest numbers of emergency cholecystectomies perform a larger proportion within 3 days of admission.