The effect of triclosan-coated sutures on the incidence of surgical site infection in laparoscopic sleeve gastrectomy, laparoscopic appendicectomy or laparoscopic cholecystectomy: A multi-centre, double-blind, randomized, intra-individual study.

Surgical site infection (SSI) is a common cause of post-operative morbidity. According to the latest report announced by CDC, the SSI accounts for 20% of healthcare-associated infection with a high risk of mortality up to twofold to 11-fold increase with high economic burden for the prolonged hospital stay. Port site infection (PSI) is a subgroup of SSI occurring at the ports of laparoscopy. We tried to determine the efficacy of polyglactin 910 suture coated with triclosan in lowering the rate of PSI in some of the clean-contaminated wound surgeries. This study included 480 individuals eligible for laparoscopic cholecystectomy, appendicectomy or sleeve operations. Polyglactin 910 sutures coated with triclosan were used in one port site incision while polyglactin 910 sutures were used in the other port sites incisions. In patients who underwent laparoscopic cholecystectomy and appendicectomy, the incidence of PSI was significantly lower in the triclosan-coated sutures. In sleeve gastrectomy patients, although a lower number of triclosan-coated sutures developed PSI, there was no statistically significant difference between triclosan and non-triclosan-coated sutures. This study showed that using sutures coated with antiseptics like triclosan has clinical benefits to prevent SSIs in most of the laparoscopic surgeries.

Occlusion of the cystic duct with cyanoacrylate glue at laparoscopic subtotal fenestrating cholecystectomy for a difficult gallbladder.

BACKGROUND: Subtotal cholecystectomy is occasionally the management of choice in the patient with a hostile Calot's triangle but when it is not considered safe to close the cystic duct this often leads to a biliary fistula. In order to reduce this morbidity a novel strategy to seal the cystic duct with cyanoacrylate glue was introduced. The outcome of the two strategies have been compared. METHODS: Patients who had a laparoscopic subtotal cholecystectomy where the cystic duct was left open, the Unsecured group, were compared with those where the duct orifice was occluded with cyanoacrylate glue, the Glued group. The outcome of the two strategies have been compared by duration of biliary drainage, whether a leak was shown on ERCP, time to removal of the drain, length of hospital stay, the re-operation and readmission rates. RESULTS: In 78 cases of laparoscopic subtotal cholecystectomy it was considered unsafe to close the cystic duct. 36 patients were managed without closure of the cystic duct, the Unsecured group and bile drainage continued for more than 3 days in 9 cases (25%) compared with 3 of 42 cases (7%) treated with glue, the Glued group (NS). Postoperative ERCP demonstrated a leak more frequently in the Unsecured group (p < 0.02). The length of stay was reduced in the Glued group. (0.9 compared with 3.0 days, p < 0.01). CONCLUSION: The results suggest that glue may be a safe option to occlude the cystic duct orifice and reduce hospital stay when this cannot safely be closed at subtotal cholecystectomy.

SIMULTANEOUS HIATAL HERNIA PLASTICS WITH FUNDOPLICATION, LAPAROSCOPIC CHOLECYSTECTOMY AND UMBILICAL HERNIA REPAIR.

The article presents a case report of patients with multimorbid pathology - hiatal hernia with gastroesophageal reflux disease, cholecystolithiasis and umbilical hernia. Simultaneous surgery was performed in all cases - laparoscopic hiatal hernia with fundoplication, laparoscopic cholecystectomy and umbilical hernia alloplasty (in three cases - by IPOM (intraperitoneal onlay mesh) method and in one - hybrid alloplasty - open access with laparoscopic imaging). After the operation in one case there was an infiltrate of the trocar wound, in one case - hyperthermia, which were eliminated by conservative methods. The follow-up result showed no hernia recurrences and clinical manifestations of gastroesophageal reflux disease.

Subhepatic mass occurrence after using oxidized and regenerated cellulose polymer in laparoscopic cholecystectomy: a case series.

BACKGROUND: Oxidized regenerated cellulose (ORC) is a bioabsorbable surgical hemostatic. We present the first prospective case series of circumscribed mass occurrence after using ORC in laparoscopic cholecystectomy. METHODS: Tabotamp (Ethicon, Inc., Somerville, NJ) in the form of tightly woven knitted patches was used to achieve hemostasis in 83 patients submitted to LC. RESULTS: A subhepatic mass was detected in five patients and radiologic characteristics were described. Abdominal contrast enhanced CT showed a heterogeneous soft-tissue mass. NMR was performed in one patient and showed a T2-weighted hyperintense mass. CONCLUSION: ORC retention after surgery is not uncommon at long-term follow-up. The radiologic characteristics of a suspected ORC retention mass can differentiate it from a neoplastic lesion, so that surgery can be avoided.

Evaluating the effects of preoperative fasting and fluid limitation.

The aim of the study was to evaluate the effects of preoperative fasting and fluid limitation in patients undergoing laparoscopic cholecystectomy. Although traditional long-term fasting is not recommended in current preoperative guidelines, this is still a common intervention. Visual analogue scale was used to assess hunger, thirst, sleepiness, exhaustion, nausea and pain; State and Trait Anxiety Inventory was used to assess the preoperative anxiety of 99 patients undergoing elective laparoscopic cholecystectomy. Mean time of preoperative fasting and fluid limitation were, respectively, 14.70 ± 3.14 and 11.25 ± 3.74 h. Preoperatively, 58.60% of the patients experienced moderate anxiety. Patients fasting 12 h or longer had higher hunger, thirst, nausea and pain scores. The mean trait anxiety score of patients fasting 12 h or longer was statistically significantly higher. Receiving nothing by mouth after midnight preoperatively is a persisted intervention and results in discomfort of patients. Clinical protocols should be revised and nurses should be trained in current fasting protocols.

Infiltration of liposome bupivacaine into the transversus abdominis plane for postsurgical pain management in a 39-year-old female undergoing laparoscopic cholecystectomy.

INTRODUCTION: Pain after laparoscopic cholecystectomy is reportedly complex and multifaceted, and has been cited as the most frequent reason for prolonged convalescence. The use of opioid therapy, a common pain management strategy, can be limited by potentially severe adverse events. In this report, I describe the use of liposome bupivacaine, administered via transversus abdominis plane (TAP) infiltration, in a patient undergoing emergency laparoscopic cholecystectomy. CASE: The patient underwent an emergency laparoscopic cholecystectomy complicated by an unexpected correction of partially detached mesh implanted during prior ventral hernia repair. The patient was discharged to the post-anesthesia care unit, but reported a pain score of 8 (11-point scale; 10 = worst possible pain). Fentanyl rescue therapy failed to alleviate the pain. Liposome bupivacaine was administered via bilateral TAP infiltration as postsurgical rescue pain medication, part of a multimodal analgesic regimen. RESULTS: The patient tolerated the TAP infiltration well and subsequently reported a pain score of 2 and a pain satisfaction score of 10 (11-point scale; 10 = completely satisfied). No additional analgesics were required. The patient was discharged on postoperative day 1, resumed normal activities in <24 hours, and remained satisfied with the pain management for 5 days. DISCUSSION: TAP infiltration of liposome bupivacaine was associated with improvement in postsurgical pain control, eliminated the need for additional opioids, and reduced the length of hospital stay from the usual 3 days to <24 hours. CONCLUSIONS: Liposome bupivacaine administered via TAP infiltration shows potential as part of a multimodal analgesic regimen in laparoscopic cholecystectomy.

Preoperative oral feeding reduces stress response after laparoscopic cholecystectomy.

BACKGROUND/AIMS: Fasting period before surgery may change metabolic status of the patient and have influence on perioperative stress response. The aim of the study was to investigate effects of preoperative carbohydrate-rich beverage on stress response after laparoscopic cholecystectomy. METHODOLOGY: Patients admitted for laparoscopic cholecystectomy were included into study and they were randomized into a group that was fed prior to surgery and in a group that was in the regime of nothing by mouth from the evening one day before surgery. Concentrations of C-reactive protein and cortisol, were measured before and subsequently up to 48 h postoperatively. RESULTS: Postoperative serum C-reactive protein increased significantly in both groups, but the increase was more evident in the group with fasting protocol both 24 and 48 hours postoperatively. In fed patients cortisol concentration measured in the afternoon immediately after the operation showed physiological decline. In patients with fasting protocol postoperative cortisol values rise above the values measured in the morning. CONCLUSIONS: Preoperative feeding has advantage over overnight fasting by reducing preoperative discomfort in patients after laparoscopic cholecystectomy. In fed patients, smaller increase in C-reactive protein and better regulation of cortisol levels are an indicator of decreased perioperative stress response.

[Hemobilia as a late complication after laparoscopic cholecystectomy--endovascular treatment]. / Hemobilia jako pózne powiklanie po cholecystektomii laparoskopowej--leczenie wewnatrznaczyniowe.

A case of 57-year-old woman with hepatic artery pseudoaneurysm associated with fistula into the biliary tract following laparoscopic cholecystectomy. Because of mechanical barrier presence, constricted the blood vessel leading blood into the aneurysm, endovascular embolization with histoacrylate glu was used as a treatment. The use of histoacrylate glu is an effective alternative in hepatic artery pseudoaneurysms treatment, which allowed to get haemostasis by endovascular embolization, especially in cases when it is impossible to use standardly applied microcoils.

How should we secure the cystic duct during laparoscopic cholecystectomy? A UK-wide survey of clinical practice and systematic review of the literature with meta-analysis.

INTRODUCTION: It is currently unknown which method of cystic duct closure is most effective at reducing the risk of bile leak after laparoscopic cholecystectomy. The aims of this work were to determine the most common closure methods used in the UK and review available evidence on which method has the lowest risk of bile leak. METHODS: We conducted an online survey through the Association of Upper Gastrointestinal Surgeons (AUGIS). We also undertook a systematic review using PubMed, EMBASE, MEDLINE and the Cochrane Library for studies that compared different methods for cystic duct occlusion and reported postoperative bile leak. FINDINGS: There was significant variation in practice between consultant surgeons. For routine laparoscopic cholecystectomy metal clips were used most (64%) followed by locking polymer clips (33%) and suture ties (3%). In cases of a dilated cystic duct, preferences were locking polymer clips (60%), suture ties (30%) and metal clips (5%). We included six studies in our review with a total of 8,011 patients. Metal clips were associated with an increased odds of bile leak compared with locking polymer clips (OR 5.66, 95% CI 1.13-28.41, p=0.04) or suture ties (OR 4.17, 95% CI 0.72-24.31, p=0.12). Most studies were retrospective, unlikely to be adequately powered, and vulnerable to selection bias. CONCLUSIONS: Limited available evidence suggests that metal clips have the highest risk of bile leak, but results are not strong enough to recommend a change in current clinical practice. A trial is now required to determine the best method of cystic duct closure.

Challenging airway in a postmandibulectomy patient for carcinoma of the buccal mucosa undergoing laparoscopic cholecystectomy.

Failure to secure the airway after administration of induction agent in a postmandibulectomy patient can lead to life-threatening complications; hence, recognising a difficult airway is of immense importance. Preoperative airway evaluation includes, but is not limited to, inter-incisor gap, modified Mallampati grading, neck movement, neck circumference, thyromental distance, sterno-mental distance, upper lip bite test and dental status. This case signifies the challenge encountered in securing the airway and the importance of thorough preoperative airway evaluation and preparedness before induction of anaesthesia in a postmandibulectomy patient for carcinoma of the buccal mucosa.

Clipless cholecystectomy: which sealer should be used?

BACKGROUND: The use of the Harmonic Scalpel (HS) for cystic duct ligation began with little data about its efficacy or safety. On the other hand, there is not any literature available about the use of PlasmaKinetic Sealer (PK) for closing the cystic duct in laparoscopic cholecystectomy (LC). Therefore, this study was designed to compare the efficacy and safety of HS and PK for achieving safe closure of the cystic ducts after LC. METHODS: Ninety patients with symptomatic gallstone disease were enrolled in this prospective case control study. The patients were operated with laparoscopic technic and divided into three groups (n = 30) randomly. After the dissection of Calot's triangle, proximal cystic ducts on common bile ducts were sealed with single surgical clips (SC) in all groups, and in the first group, distal of the cystic ducts also was sealed with single SC and the gallbladders were removed with SC. In the second and third groups, distal of the cystic ducts were sealed with HS and PK, respectively. The gallbladders were removed as sealed cystic ducts with HS and PK. Then, gallbladders were connected to a transducer set and increasing pressure with saline was applied. The bursting pressures of gallbladders were measured and differences between the groups were calculated by using Student's t test. The value of P < 0.05 was accepted as significant. RESULTS: In this study, the mean cystic duct bursting pressures were 332.46 ± 4.62 mmHg with SC, 326.56 ± 4.53 mmHg with PK, and 343.06 ± 4.28 mmHg with HS. Differences of the mean cystic duct bursting pressures between the groups were indicated the superior results of HS. CONCLUSIONS: The results of this study indicated that HS is more effective than PK and as safe and effective as SC for cystic duct closure.

Successful endovascular management of postoperative arterio portal fistula.

Arterioportal fistulas are rare and mostly a result of late complication of gastric and biliary surgery. Surgical excision has been the therapy of reference. Endovascular treatment is emerging as a real alternative to surgery. The present study reports a case of postsurgical arterioportal fistula involving the gastroduodenal artery, the cause of portal hypertension, which was successfully treated by transarterial embolization using embospheres. Portal hypertension improved dramatically.

Hemobilia and occult cystic artery stump bleeding after a laparoscopic cholecystectomy: endovascular treatment with N-butyl cyanoacrylate.

Hemobilia is a rare phenomenon. In this case report we present an emergent transcatheter glue embolization (in which N-butyl cyanoacrylate is used as an embolizing agent) due to arteriobilary fistula occurred following the laparoscopic cholecystectomy in a 41-year-old woman.

Port site metastases a year after initial laparoscopic cholecystectomy. Should the use of retrieval bags during laparoscopic cholecystectomy be the new gold standard?

As a result of gallbladder cancer being rare, it is often an understudied disease. There is lack of information particularly about long-term outcomes after resection during either laparoscopic or open surgery techniques [4]. There is also little data on the ways in which surgical techniques can be improved to further aid patients diagnosed with gallstones or other indications for cholecystectomy, and resulting positive histopathology. Furthermore, there is a lack of general acknowledgement on the vitality of using plastic retrieval bags during cholecystectomy regardless of the histopathology. The case study at hand shows how critical a plastic bag can be during cholecystectomy in further preventing the risk of local or distant metastasis originating from the gallbladder. This is especially important as it is estimated that almost one third of patients who undergo curative intent surgery for gallbladder cancer develop a tumor recurrence. Specifically, our patient was found to have a distant recurrence occurring a year after the elective surgery, which is in range with the usual median recurrence of 9.5 months or within the first 12 months [5]. </br> </br> Laparoscopic cholecystectomy is a common surgical procedure, and remains the gold standard for the management of benign gallbladder and biliary disease. While this procedure can be technically straightforward, there are some key factors that surgeons must take into consideration with one of them being whether to use a retrieval bag or not. According to the "Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery" of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the use of a retrieval bag for gallbladder extractions is purely at the discretion of the surgeon [6]. Generally, plastic bags should be used when gallbladder cancer is suspected to minimize disseminating tumor cells, or in the case of acute cholecystitis, to avoid spillage of gallbladder contents including possible infected bile, stones or pus. While one study states that when a cholecystectomy is performed due to gallstones, generally, surgeons will only opt for a plastic bag if there are large gallstones, great inflammation or an edematous gallbladder [7, 8]. However, another article claims the adverse, with endoscopic bags being in fact used commonly in elective cholecystectomy, despite the increased cost and apparent benefit [7]. A major drawback, and possible reason why some surgeons may decide not to use retrieval bags could be due to the extra skills needed, or increased difficulty to the surgery. This could be due to the need for enlargement of port site incision, placement of the bag around the gallbladder, as well as the potential risk to abdominal organ damage during the insertion and retrieval of the bag [7]. Sometimes the decision not to use the bag is purely economic, especially in developing countries. Fortunately nowadays commercially available endobags become more inexpensive, and to the very little extent, increase final costs of laparoscopic cholecystectomy. However, in order to reduce these costs several studies have shown that sterile male condoms or surgical non-powdered gloves can be used [9]. </br> </br> Umbilical port site recurrence is traditionally a major concern, however there is still little research around the exact mechanism responsible for port site recurrence. Port site metastasis is the most common form of parietal recurrence with all stages of gallbladder carcinoma being reported at any of the trocar sites. Historically it was proved that the risk of port site metastasis after laparoscopic removal of incidental gallbladder cancer remained at the level of 14-30% of all cases. Recent study conducted to assess the incidence of port site metastasis in incidental gallbladder cancer in the modern era (2000-2014) versus the historic era (1991-1999) proved that this incidence has decreased but is still relatively high to other primary tumors [10]. </br> </br>It generally presents after latency, ranging from a few months to 3-4 years. Many factors can contribute to port site metastasis [9]. One of the most important is intraoperative spillage of bile from gallbladder wall perforation, which has been described in 30% of laparoscopic cholecystectomy cases, and it has been linked to port site metastasis [11]. Interestingly, local recurrence was noted only in a minority of patients, with distant sites such as the liver and peritoneum being the most common sites for disease recurrence [4]. </br> </br> Some hypotheses suggest to elucidate the cause of port site metastasis, including direct "chimney stack effect" in which the cancer cells may spread along trocar wound [12]. However, recent studies indicated that the chimney effect may not be the key reason for port site metastasis after laparoscopy and other factors may play crucial role in the development of this phenomenon, such as biological invasiveness of cancer, local traumatic factors, as well as host immune response [13]. Current evidence suggests that carbon dioxide pneumoperitoneum does not enhance wound metastases following laparoscopic abdominal tumour surgery. Animal studies indicated that overall postoperative wound recurrence of cancer is not significantly different between routine and gasless laparoscopic surgery [14]. null Tissue specimens removed during surgery are examined both macroscopically and microscopically, and despite this, false negatives can still persist. While there is clear data pertaining to false negatives associated with biopsies done with FNA occurring in a staggering 11-41% to detect malignancy before surgery [15], there is little data for false negatives in the postsurgical setting. Although histopathological analysis is usually very reliable to exclude malignancy, it may fail. This is clearly evident with our case, where the result was false negative. The cause for false negativity could be due to, for example, improper sampling despite guidelines indicating that three samples ought to be taken from high-risk areas of the specimen [16]. With false positives being possible both in pre- and postsurgery biopsies, surgeons must be cautious and take this factor into account in their surgical approach [17]. </br></br> At present, the only method that is universally used to reduce the recurrence of gallbladder cancer is cholecystectomy as incision of port sites and the use of endoscopic bags have been variably used among surgeons. Moreover, the use of adjuvant therapy after cholecystectomy has not shown to decrease the rate of recurrence, however, patients who underwent chemotherapy treatment often did slightly better [4]. Port site metastases are independently associated with a worse prognosis. Resection of previous laparoscopy port sites is advised in patients with peritoneal carcinomatosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) to ensure complete cytoreduction [18]. </br></br> It is clear from this standpoint that other solutions and ideas are needed. One of these could be permanent implementation of retrieval bags during cholecystectomies, especially due to the fact that it is not always possible to foresee the problems of retraction or to show a positive histopathological result in case of gallbladder rupture [4, 17]. In every cholecystectomy there is a risk of gallbladder perforation and spread of malignant cells. Perforation of the gallbladder is in fact a frequent complication during laparoscopic cholecystectomy, with a much higher risk of perforation in acute conditions like acute cholecystitis or gallbladder empyema. Some other methods that could be used to prevent dissemination of either gallbladder contents or malignant cells include clip application, rubber band ligation or endoscopic loop application. Rubber band ligation is especially good because it is considered as a safe, simple, inexpensive method, not increasing the duration of surgery [19]. Regardless of what method a surgeon decides to use to prevent cell dissemination during cholecystectomy, it is vital that one is used, and that the guidelines are amended. This case study provides the means for this, especially since a negative histopathological biopsy still does not exclude the possibility of traces of cancerous cells being undisclosed, allowing for a potential risk of port site metastases.

Liver retraction using n-butyl-2-cyanoacrylate glue during laparoscopic cholecystectomy.

ABSTRACT: There might be a thick "protrusion" in the visceral surface of hepatic quadrate lobe during the laparoscopic cholecystectomy (LC), which affects the surgical fields and consequently triggers high risks of biliary tract injury. Although n-butyl-2-cyanoacrylate (NBCA) glue has been applied to laparoscopic upper abdominal surgery for liver retraction, there is still no consensus on its safety and feasibility in LC. In this study, we investigated the safety, feasibility, and effectiveness of liver retraction using NBCA glue for these patients which have the thick "protrusion" on the square leaf surface of the liver during LC.Fifty-seven patients presenting thick "protrusion" hepatic quadrate lobe were included in our retrospective study. We performed LC in the presence of NBCA glue (n = 30, NBCA group) and absence of NBCA glue (n = 27, non-NBCA group), respectively. NBCA was used to fix the thick "protrusion" of the liver leaves to the hepatic viscera surface, which contributed to the revelation of the gallbladder triangle. The operation time, blood loss, postoperative hospitalization, and liver function were compared between the 2 groups.Both the groups' patients accomplished the operation in the laparoscopy. There was no mortality and no additional incision during operation. No severe complications including bile duct injury were available after surgery and no postoperative NBCA-related complications occurred after 9- to 30 months' follow-up. The time of operation in NBCA group showed significant decrease compared with that of non-NBCA group (48.33 ±â€Š16.15 vs 65.00 ±â€Š22.15 minutes, P < .01). There were no significant differences in blood loss, postoperative hospital stays, and the preoperative and postoperative liver function between the two groups (P > .05). Besides, no significant differences were noticed in major clinical characteristics between the 2 groups (P > .05).Liver retraction using NBCA during LC for thick "protrusion" hepatic quadrate lobe patients is safe, effective, and feasible.

Comparison of the Effects of Haloperidol, Metoclopramide, Dexmedetomidine and Ginger on Postoperative Nausea and Vomiting After Laparoscopic Cholecystectomy.

Nausea is a mental sensation of unease and discomfort before vomiting. Vomiting refers to the return of the contents of the upper gastrointestinal tract to the mouth caused by contractions of chest and abdomen muscles. Postoperative nausea and vomiting is an unpleasant experience with high treatment costs. Therefore, this study aimed to compare the effects of haloperidol, metoclopramide, dexmedetomidine, and ginger on postoperative nausea and vomiting after laparoscopy. This double-blind clinical trial was performed on all laparoscopy candidates at Valiasr hospital, Arak, Iran. The patients were randomly divided into four groups (haloperidol, metoclopramide, dexmedetomidine and ginger), and all patients underwent general anesthesia using fentanyl, midazolam, atracurium, and propofol. After intubation, tube fixation, and stable hemodynamic conditions, the patients received four ginger capsules with a hint of lemon. A group of patients received 25 µg of dexmedetomidine. In the Plasil group, 10 mg of metoclopramide was given 30 minutes before the completion of surgery. In addition, 0.5 cc of haloperidol (5 mg) was administered to a group of patients. Heart rate, blood pressure, and oxygen saturation were recorded from the beginning of surgery, every 15 minutes until the end of the surgery. Furthermore, the occurrence of nausea and vomiting was recorded during recovery, 2 and 4 hours after surgery. Data were then analyzed using the SPSS software v.23. Eighty-eight patients were enrolled in the study. The youngest and the oldest were 30 years and 70 years old, respectively, and the mean age was 48.02 ± 9.31 years. Moreover, the number of women in the four groups was higher than that of men. Blood pressure in the dexmedetomidine group was lower than the other four groups (P <0.05). The lowest heart rate was observed in the haloperidol group, while the highest heart rate was seen in the plasil group (P <0.05). The occurrence of vomiting and nausea was not significantly different between the four groups (P <0.05). Our results showed no significant difference in postoperative nausea and vomiting between the four drugs. Due to the hemodynamic changes induced by each drug, it is best to use these drugs based on the patient's condition. Ginger is also a herbal remedy that has fewer side effects, and this drug can be a good option for patients when there is no contraindication.

A comparative study of 10-Fr vs. 7-Fr straight plastic stents in the treatment of postcholecystectomy bile leak.

BACKGROUND: Biliary decompression is a key factor in the treatment of postcholecystectomy bile leak. However, the optimal size of the stent introduced by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is yet to be determined. The aim of the study was to compare the effectiveness of two straight plastic stents with different sizes (10-Fr and 7-Fr) in the treatment of postcholecystectomy bile leak. METHODS: Between January 2003 and August 2006, 63 patients underwent therapeutic ERCP for postcholecystectomy bile leak. After visualization of the bile duct injury, endoscopic sphincterotomy was performed and the patients were randomized to receive either a 7-Fr (31 subjects, group A) or a 10-Fr (32 subjects, group B) straight plastic stent for four weeks. The success of the endoscopic treatment was determined by the elimination of the symptoms and the removal of the drain without any adverse outcomes. RESULTS: The endoscopic intervention was successful in 29 patients of group A (93.54%) and in 31 patients of group B (96.87%). In the remaining two patients of group A, the 7-Fr stent was substituted by a 10-Fr stent after 7 days because the leak remained unaffected, resulting in healing of the leaks. Surgery was required in the remaining one patient of group B. Eight patients developed post-ERCP pancreatitis (5 mild, 2 moderate, 1 severe), which was treated conservatively. CONCLUSIONS: This trial suggests that the stent size does not affect the outcome of the endoscopic intervention in postcholecystectomy bile leaks due to minor biliary tract injury; however, larger cohorts are required to confirm the optimal stent size in bile leaks due to major bile duct injury.

Pre-Operative Skin Antisepsis with Chlorhexidine Gluconate and Povidone-Iodine to Prevent Port-Site Infection in Laparoscopic Cholecystectomy: A Prospective Study.

BACKGROUND: Skin preparation with antiseptic agents is commonly recommended for incisional site cleansing before surgery. We present the result of a prospective case series submitted to a scheduled pre-operative antiseptic procedure combining chlorhexidine gluconate and povidone-iodine before elective laparoscopic cholecystectomy. PATIENTS AND METHODS: Consecutive patients underwent pre-operative standardized cleansing of the operation site combining chlorhexidine gluconate and povidone-iodine. Patients were reviewed one week and four weeks post-operatively. RESULTS: Post-operative infection was observed in seven patients (4.3%). All observed infections were port-site infections, always located at the level of the umbilical incision. In all cases infections involved skin and subcutaneous tissue. Staphylococcus aureus was isolated in five patients (71.4%) and miscellaneous aerobic gram-positive bacteria in two subjects (28.6%). Post-operative hospital stay was the only factor significantly associated with the development of port-site infections. CONCLUSIONS: Port-site infections are a common complication after elective laparoscopic cholecystectomy. The proposed pre-operative disinfection procedure is effective in reducing port-site infections. Reducing hospital stay may contribute to limiting the occurrence of this complication.

SURGISIS-assisted surgical site control in the delayed repair of a complex bile duct injury after laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy has revolutionized the surgical approach to patients with gallbladder disease, it has also brought a marked increase in the incidence of complex and serious bile duct injuries. Many of these major injuries represent a major technical challenge for even the most seasoned hepatobiliary-trained surgeon. Herein, we present a case outlining the algorithmic treatment approach for delayed-presentation complex biliary injury and report on the novel use of small intestinal submucosal biomaterial for surgical site control in the staged repair of a complex biliary injury (Strasberg E4) after laparoscopic cholecystectomy.