The incidence of biliary duct injuries remains higher in laparoscopic cholecystectomy (LC) in comparison to open surgery. The Critical View of Safety (CVS) was introduced by Strasberg as a strategy for reducing this catastrophic complication. AIM: The aim of this study was to evaluate how often an adequate CVS is achieved during LC, the determining factors for its success, and the associated surgical outcomes.
This is a prospective study. CVS photographs of all patients who underwent LC by the same surgeon between 2020 and 2023 were taken. Success in achieving CVS was analyzed by the surgeon herself and posteriorly by hepatobiliary specialists. Patients were classified into two groups: CVS achieved and CVS not achieved. Finally, multivariable logistic regression was used to examine the association between preoperatory factors and surgical complications.
Three hundred and nine consecutive patients were submitted to LC. There were 73.5% elective CL and 26.5% acute cholecystitis. The age ranged from 14 to 87 years, and 76.8% were female. The median body mass index was 26.7. Previous abdominal surgeries were present in 64%, and 26% were obese. The CVS was achieved in 79.9% of the patients, and there were no surgical complications in this group. The factors associated with nonachievement were acute cholecystitis (p=0.007), male sex (p=0.014), and previous surgeries (p=0.021). Three patients needed a subtotal cholecystectomy due to severe inflammation. There was no statistical correlation between the identification of CVS and surgical complications.
The CVS is achieved in most patients. Acute cholecystitis, male sex, and previous abdominal operations are associated with difficulties in obtaining CVS.
Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy.
To report a case of bile duct injury in a patient with situs inversus totalis.
A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis.
The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis.
Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.
Laparoscopic cholecystectomy has traditionally been performed with four incisions to insert four trocars, in a simple, efficient and safe way.
To describe a simplified technique of laparoscopic cholecystectomy with two incisions, using basic conventional instrumental.
In one incision in the umbilicus are applied two trocars and in epigastrium one more. The use of two trocars on the same incision, working in "x" does not hinder the procedure and does not require special instruments.
Simplified laparoscopic cholecystectomy with two incisions is feasible and easy to perform, allowing to operate with ergonomy and safety, with good cosmetic result.
One of the ways to avoid infection after surgical procedures is through antibiotic prophylaxis. This occurs in cholecystectomies with certain risk factors for infection. However, some guidelines suggest the use of antibiotic prophylaxis for all cholecystectomies, although current evidence does not indicate any advantage of this practice in the absence of risk factors.
This study aimed to evaluate the incidence of wound infection after elective laparoscopic cholecystectomies and the use of antibiotic prophylaxis in these procedures.
This is a retrospective study of 439 patients with chronic cholecystitis and cholelithiasis, accounting for different risk factors for wound infection.
There were 7 (1.59%) cases of wound infection. No antibiotic prophylaxis regimen significantly altered infection rates. There was a statistically significant correlation between wound infection and male patients (p=0.013). No other analyzed risk factor showed a statistical correlation with wound infection.
The non-use of antibiotic prophylaxis and other analyzed factors did not present a significant correlation for the increase in the occurrence of wound infection. Studies with a larger sample and a control group without antibiotic prophylaxis are necessary.
The cholelithiasis is disease of surgical resolution with about 60,000 hospitalizations per year in the Sistema Único de Saúde (SUS - Brazilian National Health System) of the Rio Grande do Sul state.
To describe the profile of hospitalizations for cholecystitis and cholelithiasis performed by the SUS of Rio Grande do Sul state, 2011-2013.
Hospital Information System data from the National Health System through morbidity list for cholelithiasis and cholecystitis (ICD-10 K80-K81). Variables studied were sex, age, number of hospitalizations and approved Hospitalization Authorizations (AIH), total amount and value of hospital services generated, days and average length of stay, mortality, mortality and case fatality ratio, from health regions of the Rio Grande do Sul.
During 2011-2013 there were 60,517 hospitalizations for cholecystitis and cholelithiasis, representing 18.86 hospitalizations per 10,000 inhabitants/year, most often in the age group from 60 to 69 years (41.34 admissions per 10,000 inhabitants/year) and female (27.72 hospitalizations per 10,000 inhabitants/year). The fatality rate presented an inverse characteristic: 13.52 deaths per 1,000 admissions/year for males, compared with 7.12 deaths per 1,000 admissions/year in females. The state had an average total amount spent and value of hospital services of R$ 16,244,050.60 and R$ 10,890,461.31, respectively. The health region "Capital/Gravataí Valley" exhibit the highest total expenditure and hospital services, and the largest number of deaths, and average length of stay.
The hospitalization and lethality coefficients, the deaths, the length of stay and spending related to admissions increased from 50 years old. Females had a higher frequency and higher values spent on hospitalization, while the male higher coefficient of mortality and mean hospital stay.
With the advancement of laparoscopic surgery, new techniques have been proposed and disseminated in order to reduce the surgical aggression and get better cosmetic results.
To present alternative technique for videocholecystectomy comparable to single port technique using conventional material for laparoscopic surgery.
Introduction of laparoscopic devices using two incisions; gallbladder traction with thread, exposition of Calot triangle, and ligature of cystic pedicle with polymer clips.
Nine operations were carried out with this method, without complications and no increase in operative time, being compared to conventional videocholecistectomy, however vastly superior in aesthetic results.
The technique is feasible, reproducible, showing benefits to patient´s safety
Surgical approach is still controversial in patients with acute cholecystitis: to treat clinically the inflammatory process and operate electively later or to operate immediately on an emergency basis?
To test the hypothesis that urgent laparoscopic cholecystectomy in acute cholecystitis has a higher mortality than elective laparoscopic cholecystectomy.
From the data available in Datasus, mortality was compared between patients undergoing elective laparoscopic cholecystectomy for cholelithiasis and in urgency. Calculations were made of the relative reduction in risk of death, absolute reduction of risk of death and number needed to treat.
From 2009 to 2014 in Brazil, there were 250.439 laparoscopic cholecystectomy and 74.6% were electives. Mortality in the emergency group was 4.8 times higher compared to the elective group (0.0023% vs. 0.00048%). Despite the relative reduction in risk of death (RRR) was 83%, in the calculation of absolute risk was found 0.0018 and number needed to treat of 55,555.
Despite the relative risk reduction for mortality was high comparing elective vs. urgent basis, the absolute risk reduction was minimal, since this outcome is very low in both groups, suggesting that mortality should not have much influence on surgical decision.
Bile duct injuries have various etiologies2,6. For their repair, there are several surgical techniques adjusted to the clinical situation of each patient9,10. In some common bile duct injuries round ligament repair has been suggested as an alternative to a possible biliodigestive derivation. However, the evidence with respect to its generalized use is limited1,3,8.
We present the case of a patient operated for acute cholecystitis with a bile duct injury associated with necrosis of the common bile duct that was repaired with a round ligament patch.
Laparoscopic cholecystectomy is the preferable treatment for chronic or acute cholecystitis. Some factors may increase the rate of laparoscopic conversion to open cholecystectomy and perioperative complications. The role of gender as a risk factor for laparoscopic cholecystectomy is controversial.
To evaluate the role of the gender on the operative findings and outcome of laparoscopic cholecystectomy.
All patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis were included. Demographic, clinical, laboratory, imaging exams, intraoperative and postoperative data were obtained and analyzed. The data was obtained retrospectively from electronic medical records and study protocols.
Of a total 1,645 patients who were subjected to laparoscopic cholecystectomy, 540 (32.8%) were men and 1,105 (67.2%) were women. Mean age was similar in both genders (p=0.817). Operative time has longer in the male (72.48±28.50) than in the female group (65.46±24.83, p<0.001). The rate of acute cholecystitis was higher in the male (14.3%) than in the female group (5.1%, p<0.001). There was no difference between the genders in regard to the rate of conversion (p=1.0), intraoperative complication (p=1.0), postoperative complication (p=0.571), and operative mortality (p=1.0).
Male gender is not an independent risk factor for laparoscopic conversion and perioperative complications.
Desenvolvido por Surya MKT