Leveraging access to technology and enhanced surgical technique (LATEST) in laparoscopic bile duct exploration (LBDE).

Single-stage management of choledocholithiasis with concomitant gallstones consists of performing either laparoscopic bile duct exploration (LBDE) or intra-operative endoscopic retrograde cholangiopancreatography at the same time as laparoscopic cholecystectomy. Transductal LBDE is associated with significantly higher post-operative morbidity, longer operative times and longer hospital stay when compared to transcystic LBDE. The aim of this study was to report the transcystic exploration rate and post-operative outcomes from LBDE before and after implementation of the LATEST (Leveraging Access to Technology and Enhanced Surgical Technique) principles. METHODS: A retrospective review of 481 consecutive patients between February 1998 and July 2021 was performed. Patients were assigned into two groups determined by whether they were operated before or after the implementation of LATEST. Data collected included pre-operative demographic information, medical co-morbidity, pre-operative investigations, and intra-operative findings (including transcystic exploration rate, negative choledochoscopy rate, use of holmium laser lithotripsy and operative time). Outcomes of this study were the transcystic exploration rate, stone clearance rate, conversion to open surgery, post-operative morbidity and mortality, and length of post-operative hospital stay. RESULTS: The pre-LATEST group contained 237 patients and the LATEST group comprised of 244 patients. Ultra-thin choledochoscopes and holmium laser lithotripsy were used more frequently in the LATEST group (41.4% and 18.4%, respectively). Enhanced surgical techniques (correction of the cystic duct-CBD junction and the trans-infundibular approach) were also performed more frequently in the LATEST group. More patients in the LATEST group received transcystic LBDE (86.1% vs 11.0%, p < 0.0001). The LATEST group had significantly higher stone clearance rates (98.8% vs 93.7%, p = 0.0034), reduced post-operative morbidity and shorter post-operative hospital stay (4 days vs 1 day, p < 0.0001). CONCLUSIONS: LATEST describes four key factors that can be used when performing LBDE. The adoption of LATEST in LBDE is associated with an increased stone clearance, a higher transcystic exploration rate and reduced post-operative morbidity.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration.

PURPOSE: Transcystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy. METHODS: Patients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction. RESULTS: One hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III-IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively. CONCLUSIONS: LABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

Trans-infundibular choledochoscopy: a method for accessing the common bile duct in complex cases.

PURPOSE: During laparoscopic common bile duct exploration (LCBDE) where Calot's triangle cannot be safely dissected due to a 'frozen' hepatic hilum secondary to severe inflammation or fibrosis, the preferred transcystic approach to the common bile duct (CBD) is precluded. The aim of this paper is to describe a safe method of accessing the CBD via a trans-infundibular approach (TIA) in complex cases where conventional access to the cystic duct or CBD is denied. METHODS: A retrospective review of 154 consecutive patients who underwent LCBDE at a single centre between 2014 and 2018 was performed. Outcomes of this study were successful access to the CBD to achieve choledochoscopy, successful stone clearance (when required), conversion to open surgery, total or subtotal cholecystectomy, post-operative complications, and length of hospital stay. RESULTS: Nine (5.8%) patients underwent access to the CBD via TIA choledochoscopy. TIA-LCBDE resulted in a stone extraction rate of 86% with one patient requiring choledochotomy. There were zero conversions to open surgery, and total/near total cholecystectomy was achieved in all patients. One patient suffered a post-operative complication for bilateral atelectasis and lower respiratory tract infection. Median length of hospital stay was 3 days. CONCLUSIONS: The use of a trans-infundibular approach to the CBD is indicated when the hepatic hilum is 'frozen' with severe inflammation and/or fibrosis precluding safe dissection of the critical structures within Calot's triangle. This strategy enables exploration of the CBD via the transcystic route without the need for critical view dissection or choledochotomy.

De Garengeot's hernia: A masked abdominal perforation.

INTRODUCTION: de Garengeot's hernias occur when an inflamed appendix is encased within a femoral sac. This is a relatively rare type of femoral hernia. As a result, there are currently no guidelines for the management of these hernias. CASE: We present a 90-year-old woman with a de Garengeot's hernia complicated with strangulation and perforation. The diagnosis was made intraoperatively, and it was managed with hernia repair and an appendicectomy. There were no postoperative complications. DISCUSSION: The presentation of de Garengeot's hernias is non-specific. Enclosure of the bowel content within the hernia sac may mask systemic systems of disease. Rarely, septic signs or symptoms are identified on presentation. It is typically diagnosed intraoperatively, thus prompt emergency surgery should not be delayed by clinicians awaiting precise knowledge of the sac content via imaging. Prompt surgery with a single McEvedy incision enables treatment for both the appendicitis and abdominal wall defect, an appendectomy and hernia repair, respectively. In patients that present with an irreducible femoral hernia and biochemistry suggestive of an acute inflammatory process, there should be a high clinical suspicion for de Garengeot's hernia due to the risk of perforation being masked by an anatomical encasement around the perforated bowel content.

Perioperative group and save testing are not routinely indicated for emergency laparoscopic appendicectomy and laparoscopic hernia repairs: A North West London retrospective study.

INTRODUCTION: Two valid group and saves are commonly required for patients undergoing laparoscopic appendicectomy and laparoscopic hernia repairs preoperatively; however, perioperative blood transfusions are seldom required. This is financially burdensome and frequently leads to delays in theatre lists. We performed a retrospective analysis to investigate blood transfusions performed perioperatively and within 28 days of these procedures. METHOD: We used our electronic records to collect data of all laparoscopic appendectomies and laparoscopic hernia repairs between March 2017 and March 2021. Patients of any age undergoing these operations were included. Patients requiring concomitant intra-abdominal surgery or who had incomplete medical records were excluded. RESULTS: A total of 1891 patients were included, of which 1462 (77.3%) had a laparoscopic appendicectomy versus 429 (22.7%) who had a laparoscopic hernia repair. In all, 3507 group and saves were taken costing £47,398.50. One patient (0.068%) required emergency blood transfusion (4 units of red cells) secondary to major haemorrhage. CONCLUSION: Our findings demonstrate that the incidence of perioperative blood transfusions for laparoscopic appendicectomy and laparoscopic hernia repairs is low, challenging the indication for routine preoperative group and saves.

Mitigating surgical emergency practice during COVID-19 pandemic?

PURPOSE: To define the change in Emergency Surgical Unit (ESU) workload during the COVID-19 pandemic. METHODS: Patient data for a three-week period was prospectively collected for ESU patients during lockdown period and compared to the ESU workload for the same time period prior to lockdown. RESULTS: Surgical emergencies admissions reduced by 2.5 times during our study period (p value = 0.001). In this changed paradigm, the overall number of surgical emergencies were reduced. A high mortality (n = 4, 5.7%) was noted during lockdown period as compared to pre-lockdown period (n = 1, 0.58%, p value = 0.025). Almost half of surgical admissions were tested for COVID-19 based on their symptoms and more than third (n=14, 38.9%) of them were positive. Gastrointestinal symptoms were common in COVID-19 positive group (85.7%) and only a third (36%) of COVID-19 positive patients needed surgical attention. Chest x-ray findings were comparable to PCR testing in terms of sensitivity and specificity but CT chest was more sensitive. CONCLUSIONS: It remains unclear how COVID-19 reduced surgical emergencies. A significant proportion of COVID-19 presented with gastrointestinal symptoms. In a new outbreak all General Surgical patients should be tested with CRP and WCC used as a triage adjunct. KEY WORDS: Coronavirus, COVID-19, Emergency Surgery Pandemic, General Surgery.