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Background: Laparoscopic cholecystectomy (LC) is commonly performed in patients who can pose technical challenges, such as obesity, prior surgery, and subsequent incisional hernias. A new technique, the subcostal trocar approach u...
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Background: Laparoscopic cholecystectomy (LC) is commonly performed in patients who can pose technical challenges, such as obesity, prior surgery, and subsequent incisional hernias. A new technique, the subcostal trocar approach using four 5-mm with exclusive removal (STAUFFER) LC, was developed to diminish these impediments and is highly advantageous. Methods: A retrospective review was performed of medical records for 389 patients who underwent LC from June 2011 through December 2016. STAUFFER LC involves (1) steep patient positioning, (2) visualized 5-mm trocar entry in the right abdomen, (3) use of three additional right subcostal trocars, and (4) gallbladder extraction from the high right lateral trocar site. Patient characteristics, operative details, and outcomes were analyzed and compared. Results: STAUFFER LC was used in 255 patients (65.6%), and standard four-trocar LC (SLC) was performed in 134 patients (34.4%). Overall indications for surgery included chronic cholecystitis (71.7%), acute cholecystitis (19.8%), polyp (2.3%), and other (5.9%). No significant differences were detected in comorbidities and American Society of Anesthesiologists classification between the two patient groups. More patients in the STAUFFER LC group had previous midline abdominal surgery ( P = .06) and significantly higher body mass index ( P = .03), and they required less operative time ( P Conclusions: STAUFFER LC is widely applicable and effective, saving operative time and reducing the risk of TSH. It is especially advantageous for obese patients who have had previous surgery.
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A residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period. This study involved a retrospe...
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A residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period. This study involved a retrospective analysis of patients managed for symptomatic RGB from January 2000 to December 2015. A RGB was observed in 93 patients, who had a median age of 45 (25-70) years, and were comprised of 69 (74.2%) females. The most common presentation was recurrence pain (n=64, 68.8%). Associated choledocholithiasis was present in 23 patients (24.7%). An ultrasonography (USG) failed to diagnose RGB calculi in 10 (11%) patients; whereas, magnetic resonance cholangio-pancreatography (MRCP) accurately diagnosed RGB calculi in all the cases except for 2 (4%) and, additionally, detected common bile duct (CBD) stones in 12 patients. Completion cholecystectomy was performed in all patients (open 45 [48.4%]; laparoscopic 48 [51.6%] and 19 [20.4%] patients required a conversion to open). The RGB pathology included stones in 90 (96.8%), Mirizzi's syndrome in 10 (10.8%) and an internal fistula in 9 (9.7%) patients. Additional procedures included CBD exploration (n=6); Choledocho-duodenostomy (n=4) and Roux-en-Y hepatico-jejunostomy (n=3). The mortality and morbidity were nil and 11% (all wound infection), respectively. Two patients developed incisional hernia during follow up. The mean follow up duration was 23.1 months (3-108) in 65 patients and the outcome was excellent and good in 97% of the patients. Post-cholecystectomy recurrent biliary colic should raise suspicion of RGB. MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.
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Backgrounds/Aims:Multiport laparoscopic cholecystectomy is the standard surgical procedure for symptomatic gallbladder diseases. However, as a result of the ongoing trend toward minimally invasive laparoscopy, single-incision lapa...
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Backgrounds/Aims:Multiport laparoscopic cholecystectomy is the standard surgical procedure for symptomatic gallbladder diseases. However, as a result of the ongoing trend toward minimally invasive laparoscopy, single-incision laparoscopic cholecystectomy (SILC) has evolved. Single-incision robotic cholecystectomy (SIRC) can overcome several limitations of manual SILC. The purpose of this study is to evaluate and compare the safety and feasibility of SIRC and SILC.Methods:This study retrospectively reviewed data for all patients who underwent SIRC or SILC from March 2018 to July 2019 in a single institution. The following variables were analyzed: age, sex, body mass index, pain scale, length of stay, and complications. The data were analyzed using the Independent two sample t-test or the Fisher's exact test.Results:A total of 343 patients underwent SIRC or SILC during the study period. After excluding patients with acute cholecystitis, 197 SIRC and 103 SILC patients were analyzed in this study. The surgery time and postoperative hospital stay did not differ between SIRC and SILC. However, the SIRC patients experienced less bile spillage during the surgery than did the SILC patients (SIRC vs. SILC: 24 (23.3%) vs. 11 (5.6%) cases, respectively; p<0.001). Although there was no difference in the incidence of postoperative complications between procedures, additional pain control was administered more frequently in SILC patients (SILC 1.08±0.893, SIRC 0.58±0.795; p<0.001).Conclusions:While both SILC and SIRC are effective for single-incision cholecystectomy, SIRC was superior to SILC in terms of technical stability. Moreover, it has the advantage of postoperative pain control.
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Introduction: Laparoscopic cholecystectomy is the most commonly performed surgical procedure of digestive tract. It has replaced open cholecystectomy as gold standard treatment for cholelithiasis and inflammation of gallbladder.? ...
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Introduction: Laparoscopic cholecystectomy is the most commonly performed surgical procedure of digestive tract. It has replaced open cholecystectomy as gold standard treatment for cholelithiasis and inflammation of gallbladder.? It is estimated that approximately 90% of cholecystectomies in the? United States are performed using a laparoscopic approach.? The aim of this study was to evaluate the outcome of Laparoscopic cholecystectomy in context to its complications, morbidity and mortality in a tertiary care hospital.? Methods: This retrospective study was conducted on 1200 patients, who underwent laparoscopic cholecystectomies, during the period from January 2019 to December 2019, at Government Medical College Jammu J & K, India and necessary data was collected and reviewed. Results: In our study, a total of 1200 patients were studied including 216 males (18%) and 984 females (82%). The mean age of the patients was 43.35±8.61. The mean operative time in our study was 55.5±10.60 minutes with range of 45 – 90 minutes. Conversion rate was 2.6%. 2 patients were re-explored. Bile duct injury was found in 6 patients (0.5%).? Conclusions: Gallstone disease is a global health problem. Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first choice of treatment for gallstones. Gall stone diseases is most frequently encountered in female population. The risk factors for conversion to open cholecystectomy include male gender, previous abdominal surgery, acute cholecystitis, dense adhesions and fibrosis in Calot’ s triangle, anatomical variations, advanced age, comorbidity, obesity, suspicion of common bile duct stones, jaundice, and decreased surgeon experience. The incidence of surgical site infection has significantly decreased in laparoscopic cholecystectomy compared to open cholecystectomy. In our study we could not find any case of surgical site infection.
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Abstract Background Upon encountering a difficult cholecystectomy in which, after a reasonable trial of dissection, anatomical identification has not been attained due to severe inflammation, and the risk of additional dissection ...
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Abstract Background Upon encountering a difficult cholecystectomy in which, after a reasonable trial of dissection, anatomical identification has not been attained due to severe inflammation, and the risk of additional dissection is deemed to be hazardous, “bail-out” strategies are encouraged safety valves. One strategy is to abort the cholecystectomy and refer the patient to a HPB center for further management.Methods A retrospective review was conducted of cholecystectomies performed by HPB surgeons at our center between 2005 and 2019. We identified 63 patients who had an aborted cholecystectomy because of acute or chronic cholecystitis and were referred for additional care. Of these, operative notes and other clinical records were available for 43 patients who were included in this study.Results 42 cholecystectomies (98%) were started laparoscopically. 25 patients (58%) had chronic cholecystitis, and 18 (42%) had acute cholecystitis. 40 cases (93%) fell into the highest level of difficulty on the Nassar?scale (Grade 4). Procedures were aborted at the following stages of dissection: in 10 patients (23%), none of the gallbladder was identified; in another 11 (26%), only the dome of gallbladder was identified; the body of the gallbladder was exposed in 13 (30%); and dissection of the hepatocystic triangle was attempted unsuccessfully in 9 (21%). Following referral to our center, 30 patients (70%) were managed with total cholecystectomy while in 13 cases (30%), subtotal cholecystectomy was performed.Conclusion Aborting cholecystectomy and referring the patient to an HPB center is rarely needed but is an effective bail-out strategy for general surgeons encountering highly difficult operative conditions due to inflammation.
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Abstract Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occas...
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Abstract Background Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time.Methods Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28?years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature.Results 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%.Conclusion Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.
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Background: Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy...
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Background: Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Methods: Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. Results: There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22–63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2–175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3–7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Conclusion: Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.
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Purpose: Gallstones are one of the most common abdominal reasons for admission to hospital. The aim of this study was to analyze trends and outcomes in patients undergoing cholecystectomy with gallbladder related disease in France...
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Purpose: Gallstones are one of the most common abdominal reasons for admission to hospital. The aim of this study was to analyze trends and outcomes in patients undergoing cholecystectomy with gallbladder related disease in France from 2008 to 2014.
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Background Laparoscopic subtotal cholecystectomy (LSC) is a safe bailout procedure in situations when dissection of "critical view of safety" is not possible. After the proposed classification of subtotal cholecystectomy into "fen...
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Background Laparoscopic subtotal cholecystectomy (LSC) is a safe bailout procedure in situations when dissection of "critical view of safety" is not possible. After the proposed classification of subtotal cholecystectomy into "fenestrating" and "reconstituting" techniques in 2016, a comparative review of the outcomes of both methods is timely. Methods A literature search of the PubMed, Cochrane Library, and Web of Science database was conducted up to January 31, 2020 for studies that reported LSC. Studies reporting LSC only in patients with Mirizzi syndrome or xanthogranulomatous cholecystitis were excluded. Our analysis includes 39 studies with 1784 cases of LSC. We report a comparison of outcomes between reconstituting and fenestrating LSC on 1505 cases [935 reconstituting (62.1%) and 570 fenestrating (37.9%)]. Results Following LSC, the rate of open conversion is 7.7%, hemorrhage is 0.4%, bile duct injury is 0.3%, bile leak is 15.4%, retained stone is 4.6%, subhepatic or subphrenic collection is 2.9%, superficial surgical site infection is 2.0% and 30-day mortality is 0.2%. 8.8% of patients required postoperative endoscopic retrograde cholangiopancreatography (ERCP), 1.1% required percutaneous intervention, and 2.2% required reoperation. Compared to reconstituting LSC, fenestrating LSC has a higher incidence of open conversion (n = 58, 10.2% vs. n = 43, 4.6%, p < 0.001), retained stones (n = 38, 6.7% vs. n = 38, 4.1%, p = 0.0253), subhepatic or subphrenic collections (n = 33, 5.8% vs. n = 13, 1.4%, p < 0.001), superficial surgical site infections (n = 18, 3.2% vs. n = 14, 1.5%, p = 0.0303), postoperative ERCP (n = 82, 14.4% vs. n = 62, 6.6%, p < 0.001), and need for reoperation (n = 20, 3.5% vs. n = 12, 1.3%, p < 0.001). Conclusions Although reconstituting LSC has better outcomes, both techniques are complementary. Intraoperative findings and surgical expertise impact the choice.
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Aim : To assess the causes, frequency and time of conversion from laparoscopic to classic cholecystectomy in our own material. Material and methods : 547 patients were qualified for laparoscopic cholecystectomy in the Surgery Depa...
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Aim : To assess the causes, frequency and time of conversion from laparoscopic to classic cholecystectomy in our own material. Material and methods : 547 patients were qualified for laparoscopic cholecystectomy in the Surgery Department of the Mogilno District Hospital in Strzelno during the period of 1999-2005; 515 minimally invasive operations were performed and 32 patients required conversion. Results : The 547 patients were qualified for the laparoscopic operation; of these 148 were operated on as emergency cases and 399 as elective cases. There were 20 conversions among emergency patients and 12 conversions among elective patients. On average the decision to convert was made in the 35th min of the operation. The shortest time to conversion was 15 min and the longest was 90 min. Five conversions were performed in the 25th and 35th min and 4 in the 20th, 30th, and 40th mine. Most frequently conversions occurred between the 20th and 40th min of the procedure. Intentional conversions were performed in 27 patients. Adhesions and clumps around the gallbladder were the cause of conversion in 10 patients and that was the most frequent reason for the operative modality change. The next cause of conversion was changes observed in the course of acute cholecystitis in the form of gallbladder empyema or cholecystocele (9 patients). Small, fibrotic gallbladder, immersed in the liver, was the reason for conversion in a further 4 patients. In 4 cases the conversion was caused by difficulties in the identification of anatomical structures. Four cases of forced conversions and 1 anticipated conversion were found in the analysed material. Conclusions : A change of operative modality during laparoscopic cholecystectomy was made on average in 5.85% of operations. The average time before the conversion was 35 min. Emergency patients required a change of operative modality 4 times more often. The most frequent were intentional conversions (84%), caused by pericystic adhesions and by inflammatory changes impeding the identification of anatomical structures. The predominant cause of forced conversions was intra-operative haemorrhage.
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