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ICG fluorescent cholangiography in difficult laparoscopic cholecystectomy with inflammatory biliary fusion post-cholecystitis and pancreatitis
Laparoscopic cholecystectomy in the presence of inflammatory billiary fusion is a technically challenging procedure associated with a 0.5% risk of injury to major extrahepatic bile ducts.
Preoperative planning and intraoperative visualization of the anatomy of the biliary tree using an intraoperative cholangiogram reduces the risk or the severity of injury to major biliary ducts.
Indocyanine green cholangiography has emerged as a promising non-invasive modality for visualization of extra-hepatic biliary ducts, having the advantage of very easy use repetitively at various stages of critical areas of dissection.
This video demonstrates a laparoscopic cholecystectomy in a patient who had an emergency admission for mild acute cholecystitis (as per Tokyo guidelines, 2018) and concomitant moderately severe acute gallstone pancreatitis (revised Atlanta classification) with a preoperative MRCP predictive of biliary inflammatory fusion between the gallbladder neck and the common hepatic duct.
Consequently, we planned and performed a laparoscopic cholecystectomy with an indocyanine green cholangiogram as a non-invasive method to help identify the intraoperative anatomy of the extra-hepatic biliary ducts.
The main feature of our video is the use of indocyanine green during the difficult dissection of the gallbladder neck and exposure of the critical view of safety in Calot’s triangle as cased with clear features of significant biliary inflammatory fusion between the cystic duct and the common hepatic duct.
ICG fluorescent demonstration of the extra-hepatic biliary tree is used in real time and with ease repeatedly at several stages of this difficult dissection, facilitating a safe completion of a difficult laparoscopic cholecystectomy and may become a standard practice.
G Kumar, S Ramachandran, M Paraoan
Surgical intervention
8 months ago
370 views
7 likes
1 comment
13:21
ICG fluorescent cholangiography in difficult laparoscopic cholecystectomy with inflammatory biliary fusion post-cholecystitis and pancreatitis
Laparoscopic cholecystectomy in the presence of inflammatory billiary fusion is a technically challenging procedure associated with a 0.5% risk of injury to major extrahepatic bile ducts.
Preoperative planning and intraoperative visualization of the anatomy of the biliary tree using an intraoperative cholangiogram reduces the risk or the severity of injury to major biliary ducts.
Indocyanine green cholangiography has emerged as a promising non-invasive modality for visualization of extra-hepatic biliary ducts, having the advantage of very easy use repetitively at various stages of critical areas of dissection.
This video demonstrates a laparoscopic cholecystectomy in a patient who had an emergency admission for mild acute cholecystitis (as per Tokyo guidelines, 2018) and concomitant moderately severe acute gallstone pancreatitis (revised Atlanta classification) with a preoperative MRCP predictive of biliary inflammatory fusion between the gallbladder neck and the common hepatic duct.
Consequently, we planned and performed a laparoscopic cholecystectomy with an indocyanine green cholangiogram as a non-invasive method to help identify the intraoperative anatomy of the extra-hepatic biliary ducts.
The main feature of our video is the use of indocyanine green during the difficult dissection of the gallbladder neck and exposure of the critical view of safety in Calot’s triangle as cased with clear features of significant biliary inflammatory fusion between the cystic duct and the common hepatic duct.
ICG fluorescent demonstration of the extra-hepatic biliary tree is used in real time and with ease repeatedly at several stages of this difficult dissection, facilitating a safe completion of a difficult laparoscopic cholecystectomy and may become a standard practice.
LIVE UNCUT SURGERY: laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy.
The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected.
After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe.
Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia.
This 20-minute live uncut video is a demonstration of a gold standard procedure.
D Mutter, G Philouze, B Seeliger, J Marescaux
Surgical intervention
10 months ago
18172 views
130 likes
16 comments
30:23
LIVE UNCUT SURGERY: laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy.
The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected.
After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe.
Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia.
This 20-minute live uncut video is a demonstration of a gold standard procedure.
Laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy. The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected. After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe. Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia. This 20-minute live uncut video is a demonstration of a gold standard procedure.
D Mutter, G Philouze, B Seeliger, J Marescaux
How to
11 months ago
18149 views
129 likes
0 comments
00:30:23
Laparoscopic cholecystectomy for cholelithiasis, a gold standard procedure
This video describes an "ideal" cholecystectomy, with a stepwise approach to the cystic pedicle and the dissection of the gallbladder. This video emphasizes the key points of dissection necessary to perform a safe cholecystectomy. The initial approach aims to expose the infundibulum and to successively dissect the anterior and posterior reflection of the peritoneum. It provides a safe view of the cystic duct and the cystic artery which can be dissected in order to secure the “critical view of safety”, exposing the cystic artery clearly away from the common bile duct and the right hepatic artery. This highlights the risky parts of the dissection when rules are not respected. After complete control of the pedicle, freeing of the gallbladder in the appropriate plane avoids any oozing, keeping the operative field totally clear and safe. Finally, the video shows the extraction method for the gallbladder, allowing the procedure to be performed with three 5mm ports and one 10-12mm port, thereby limiting the risk of postoperative port-site hernia. This 20-minute live uncut video is a demonstration of a gold standard procedure.
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
B Dallemagne
Lecture
2 years ago
6814 views
878 likes
0 comments
39:17
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
Single incision laparoscopic cholecystectomy without special SILS port or roticulating instruments with routine ports and instruments
Conventional single incision laparoscopic surgery (SILS) with special ports and instruments has transformed the way people undergo cholecystectomy. However, it requires high costs as compared to routine laparoscopic cholecystectomies.
We present another way of performing a SILS cholecystectomy without any special SILS port or any special roticulating laparoscopic instruments.
One 10mm port is placed in the lower aspect of the umbilicus at a 6 o’clock position and the gallbladder is assessed for SILS suitability. Another 5mm port is placed at a 3 o’clock position through a separate incision. A mini-laparoscopic grasper (Mini-Lap Technologies) is inserted in the right subcostal region. Remaining operative steps are similar to the ones used for any standard laparoscopic cholecystectomy. Careful and skilful manipulation of the mini-laparoscopic grasper helps in anterior and posterior dissection of Calot’s triangle, while maintaining the triangle of instrumentation (which is not achievable in SILS port techniques). A critical view of safety is also nicely demonstrated before clipping and dividing any structure. For clipping the cystic artery (CA) and the cystic duct (CD), a 5mm scope is used through the 5mm port and a standard clip applicator is inserted through the 10mm port. The gallbladder is extracted through the 10mm port. The 10mm port fascia is closed.
N Jha
Surgical intervention
2 years ago
2029 views
161 likes
0 comments
09:55
Single incision laparoscopic cholecystectomy without special SILS port or roticulating instruments with routine ports and instruments
Conventional single incision laparoscopic surgery (SILS) with special ports and instruments has transformed the way people undergo cholecystectomy. However, it requires high costs as compared to routine laparoscopic cholecystectomies.
We present another way of performing a SILS cholecystectomy without any special SILS port or any special roticulating laparoscopic instruments.
One 10mm port is placed in the lower aspect of the umbilicus at a 6 o’clock position and the gallbladder is assessed for SILS suitability. Another 5mm port is placed at a 3 o’clock position through a separate incision. A mini-laparoscopic grasper (Mini-Lap Technologies) is inserted in the right subcostal region. Remaining operative steps are similar to the ones used for any standard laparoscopic cholecystectomy. Careful and skilful manipulation of the mini-laparoscopic grasper helps in anterior and posterior dissection of Calot’s triangle, while maintaining the triangle of instrumentation (which is not achievable in SILS port techniques). A critical view of safety is also nicely demonstrated before clipping and dividing any structure. For clipping the cystic artery (CA) and the cystic duct (CD), a 5mm scope is used through the 5mm port and a standard clip applicator is inserted through the 10mm port. The gallbladder is extracted through the 10mm port. The 10mm port fascia is closed.
Laparoscopic subtotal cholecystectomy
Laparoscopic cholecystectomy is a hazardous operation when the anatomy of Calot’s triangle is distorted by acute inflammation or any other factor (in our case, adhesions due to the recent surgery, and especially due to radiotherapy). In these difficult situations, the intraoperative decision to use a protective surgical technique as subtotal cholecystectomy is made with the purpose to prevent any injury to the biliary tree.
This video demonstrates the case of a 69-year-old woman with morbid obesity (BMI of 55) and diagnosed with acute cholecystitis. Her past medical history is relevant for right nephrectomy for renal carcinoma using a right subcostal laparotomy followed by radiochemotherapy completed 3 months earlier.
Subtotal cholecystectomy is a procedure which aims to remove portions of the gallbladder when structures of Calot’s triangle cannot be safely identified in "difficult gallbladders". The conversion rate to open surgery was higher among this category of patients. We describe our experience with a technical change, namely, a tactical laparoscopic subtotal cholecystectomy which almost always prevents conversion at the end of the procedures, and prevents both the risk of injury to the common bile duct and the risk of hemorrhage. In such cases, there is a need for rigor and prudence in order to return to the traditional technique in real time, if necessary.
Laparoscopic subtotal cholecystectomy can be considered a safe and feasible alternative to conversion to open surgery. Subtotal cholecystectomy is an essential technique to be used in difficult gallbladders. It achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases.
A Cotirlet, M Nedelcu
Surgical intervention
3 years ago
5081 views
286 likes
0 comments
20:31
Laparoscopic subtotal cholecystectomy
Laparoscopic cholecystectomy is a hazardous operation when the anatomy of Calot’s triangle is distorted by acute inflammation or any other factor (in our case, adhesions due to the recent surgery, and especially due to radiotherapy). In these difficult situations, the intraoperative decision to use a protective surgical technique as subtotal cholecystectomy is made with the purpose to prevent any injury to the biliary tree.
This video demonstrates the case of a 69-year-old woman with morbid obesity (BMI of 55) and diagnosed with acute cholecystitis. Her past medical history is relevant for right nephrectomy for renal carcinoma using a right subcostal laparotomy followed by radiochemotherapy completed 3 months earlier.
Subtotal cholecystectomy is a procedure which aims to remove portions of the gallbladder when structures of Calot’s triangle cannot be safely identified in "difficult gallbladders". The conversion rate to open surgery was higher among this category of patients. We describe our experience with a technical change, namely, a tactical laparoscopic subtotal cholecystectomy which almost always prevents conversion at the end of the procedures, and prevents both the risk of injury to the common bile duct and the risk of hemorrhage. In such cases, there is a need for rigor and prudence in order to return to the traditional technique in real time, if necessary.
Laparoscopic subtotal cholecystectomy can be considered a safe and feasible alternative to conversion to open surgery. Subtotal cholecystectomy is an essential technique to be used in difficult gallbladders. It achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases.
Hybrid NOTES transvaginal cholecystectomy using 2 instruments (2.2mm and 3mm)
A 79-year-old patient presented with symptomatic cholecystolithiasis without signs of cholecystitis. Biochemical parameters were normal. Sonography showed large gallstones, which is a good indication for a transvaginal approach.
As we know, NOTES (natural orifice transluminal endoscopic surgery) is under constant evolution. Last year, hybrid procedures gained more importance. In our surgical department, we perform these procedures as a valid alternative for conventional laparoscopy. We observed that out patients have less pain, faster recovery, and at last almost no scar and are not at risk for incisional hernias.
With this video, we describe a comfortable 2 instrument technique using a hybrid transvaginal approach. A pneumoperitoneum of 12mmHg is created using a Veress needle at the umbilicus. A 3mm port is placed. A percutaneous clamp is placed with a diameter of 2.2mm. The patient is placed in a Trendelenburg position, and the transvaginal trocar, 12mm in diameter and 15cm in length, is pushed into the posterior fornix. A conventional cholecystectomy is performed with no loss of triangulation. Transvaginal clipping (by means of a large 45cm clip applier) and extraction are performed. Transabdominal scars are closed with a simple bandage and no suturing. The colpotomy is closed using separate Vicryl 2/0 sutures.
The procedure took 30 minutes. In our group, we have a mean operating time of 30 minutes for hybrid transvaginal cholecystectomies.
S Heyman, B Gypen, F van Sprundel, J Valk, L Hendrickx
Surgical intervention
3 years ago
1197 views
44 likes
0 comments
05:08
Hybrid NOTES transvaginal cholecystectomy using 2 instruments (2.2mm and 3mm)
A 79-year-old patient presented with symptomatic cholecystolithiasis without signs of cholecystitis. Biochemical parameters were normal. Sonography showed large gallstones, which is a good indication for a transvaginal approach.
As we know, NOTES (natural orifice transluminal endoscopic surgery) is under constant evolution. Last year, hybrid procedures gained more importance. In our surgical department, we perform these procedures as a valid alternative for conventional laparoscopy. We observed that out patients have less pain, faster recovery, and at last almost no scar and are not at risk for incisional hernias.
With this video, we describe a comfortable 2 instrument technique using a hybrid transvaginal approach. A pneumoperitoneum of 12mmHg is created using a Veress needle at the umbilicus. A 3mm port is placed. A percutaneous clamp is placed with a diameter of 2.2mm. The patient is placed in a Trendelenburg position, and the transvaginal trocar, 12mm in diameter and 15cm in length, is pushed into the posterior fornix. A conventional cholecystectomy is performed with no loss of triangulation. Transvaginal clipping (by means of a large 45cm clip applier) and extraction are performed. Transabdominal scars are closed with a simple bandage and no suturing. The colpotomy is closed using separate Vicryl 2/0 sutures.
The procedure took 30 minutes. In our group, we have a mean operating time of 30 minutes for hybrid transvaginal cholecystectomies.
Laparoscopic cholecystectomy for phlegmonous acute cholecystitis
This video demonstrates the early surgical management of a 3-day history of acute cholecystitis in an 83-year-old patient. This patient was admitted to the emergency department for epigastric and right hypochondrium pain, without any other symptoms. Clinically, the patient presented with a localized abdominal guarding; Murphy’s sign was positive. Blood chemistries demonstrated the presence of an inflammatory syndrome and liver function tests were normal. The ultrasound exam confirmed the diagnosis of acute cholecystitis. A laparoscopic cholecystectomy was decided upon. The postoperative outcome was uneventful and the patient was discharged on postoperative day 3. Laparoscopic cholecystectomy is the gold standard for the early treatment of acute cholecystitis with an onset of symptoms less than 72 hours (Tokyo Guidelines 2013, recommendation 1, grade A).
O Perotto, H Jeddou, D Mutter, J Marescaux
Surgical intervention
4 years ago
6993 views
272 likes
0 comments
10:57
Laparoscopic cholecystectomy for phlegmonous acute cholecystitis
This video demonstrates the early surgical management of a 3-day history of acute cholecystitis in an 83-year-old patient. This patient was admitted to the emergency department for epigastric and right hypochondrium pain, without any other symptoms. Clinically, the patient presented with a localized abdominal guarding; Murphy’s sign was positive. Blood chemistries demonstrated the presence of an inflammatory syndrome and liver function tests were normal. The ultrasound exam confirmed the diagnosis of acute cholecystitis. A laparoscopic cholecystectomy was decided upon. The postoperative outcome was uneventful and the patient was discharged on postoperative day 3. Laparoscopic cholecystectomy is the gold standard for the early treatment of acute cholecystitis with an onset of symptoms less than 72 hours (Tokyo Guidelines 2013, recommendation 1, grade A).
Unintentional dissection of the common bile duct
This video demonstrates the case of an 81-year-old woman with chronic cholecystitis. She has had several episodes of right hypochondrium pain with altered liver tests, which spontaneously got back to normal values. Ultrasound and CT-scan demonstrated the presence of uncomplicated gallstones and a slightly hypotonic common bile duct (8mm in diameter). No obstacle was visualized in the common bile duct. A delayed laparoscopic cholecystectomy was scheduled. This video shows how some inaccuracies in the dissection technique and the presence of an altered anatomy have led to a circumferential dissection of the common bile duct. Common bile duct injury was avoided and the importance of an intraoperative cholangiography is emphasized.
M Ignat, N Malibary, D Mutter, J Marescaux
Surgical intervention
4 years ago
3820 views
137 likes
0 comments
06:50
Unintentional dissection of the common bile duct
This video demonstrates the case of an 81-year-old woman with chronic cholecystitis. She has had several episodes of right hypochondrium pain with altered liver tests, which spontaneously got back to normal values. Ultrasound and CT-scan demonstrated the presence of uncomplicated gallstones and a slightly hypotonic common bile duct (8mm in diameter). No obstacle was visualized in the common bile duct. A delayed laparoscopic cholecystectomy was scheduled. This video shows how some inaccuracies in the dissection technique and the presence of an altered anatomy have led to a circumferential dissection of the common bile duct. Common bile duct injury was avoided and the importance of an intraoperative cholangiography is emphasized.
Diagnosis and treatment of symptomatic common bile duct stones following cholecystectomy by means of EUS and ERCP
A post-cholecystectomy syndrome is a well-known condition, which includes dyspepsia and biliary-like abdominal pain coupled with deterioration of liver enzymes. Biliary factors responsible for a post-cholecystectomy syndrome could be the following: biliary iatrogenic duct strictures, retained stones in the common bile duct (CBD), cystic stump, or even a gallbladder remnant.
The diagnosis of stones is difficult to establish considering that even trans-abdominal ultrasonography has a diagnostic sensitivity of only 27%. Conversely, endoscopic ultrasound (EUS) is a very useful tool to diagnose stones in such situations, allowing to perform subsequent ERCP and stone extraction during the same anesthetic session. Here, we report the case of a 69-year-old man who underwent laparoscopic cholecystectomy and who was referred to us after 24 hours of abdominal colic pain and cholestasis. He underwent EUS, which diagnosed residual common bile duct stones. As a result, treatment was performed by means of ERCP during the same session.
Gf Donatelli, F Cereatti, B Meduri
Surgical intervention
4 years ago
1506 views
62 likes
0 comments
03:26
Diagnosis and treatment of symptomatic common bile duct stones following cholecystectomy by means of EUS and ERCP
A post-cholecystectomy syndrome is a well-known condition, which includes dyspepsia and biliary-like abdominal pain coupled with deterioration of liver enzymes. Biliary factors responsible for a post-cholecystectomy syndrome could be the following: biliary iatrogenic duct strictures, retained stones in the common bile duct (CBD), cystic stump, or even a gallbladder remnant.
The diagnosis of stones is difficult to establish considering that even trans-abdominal ultrasonography has a diagnostic sensitivity of only 27%. Conversely, endoscopic ultrasound (EUS) is a very useful tool to diagnose stones in such situations, allowing to perform subsequent ERCP and stone extraction during the same anesthetic session. Here, we report the case of a 69-year-old man who underwent laparoscopic cholecystectomy and who was referred to us after 24 hours of abdominal colic pain and cholestasis. He underwent EUS, which diagnosed residual common bile duct stones. As a result, treatment was performed by means of ERCP during the same session.
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
D Ntourakis, D Mutter, J Marescaux
Surgical intervention
4 years ago
3296 views
126 likes
1 comment
20:03
Acute gangrenous cholecystitis with biliary peritonitis in a diabetic patient: laparoscopic cholecystectomy
This video demonstrates an early laparoscopic cholecystectomy in a diabetic 49-year-old female patient with acute gangrenous cholecystitis and biliary peritonitis. She was admitted to the emergency department with retrosternal pain radiating towards the epigastrium associated with vomiting and fever for the past 3 days. During clinical examination, she had signs of acute cholecystitis without jaundice. Her blood tests showed an important systemic inflammatory reaction without alteration of liver function tests (LFT). Finally, imaging studies (ultrasound and CT-scan) confirmed an acute calculous cholecystitis with signs of gallbladder wall ischemia and peritoneal-free fluid.
A technically challenging early laparoscopic cholecystectomy with preoperative cholangiogram was performed. The disease was controlled and the postoperative course was uneventful with patient discharge 4 days after the operation.
Early laparoscopic cholecystectomy is the standard of care for patients with mild acute cholecystitis and an onset of symptoms of less than 72 hours (Tokyo Guidelines 2013, Recommendation 1, Level A) [1]. Patients with severe local inflammation of the gallbladder presenting factors such as >72 hours from the onset, a white blood cell count >18,000, and a palpable tender mass in the right upper abdominal quadrant have grade II (moderate) cholecystitis. For these patients, a conservative treatment with gallbladder drainage can be proposed followed by delayed cholecystectomy, as early cholecystectomy can be technically challenging. Early cholecystectomy for moderate (grade II) acute cholecystitis is recommended in experienced centers [2].
A recent Cochrane meta-analysis of 5 RCTs demonstrated that there was no significant difference in the proportion of people who developed bile duct injury, nor in the proportion of people who required conversion to open cholecystectomy in patients with acute cholecystitis. Total hospital stay was 4 days shorter in the early cholecystectomy group as compared to the delayed cholecystectomy group. About 20% of the people belonging to the delayed cholecystectomy group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy. However, since the incidence of major complications is rare (about 0.2%) in cholecystectomy, a trial would have to include 50,000 patients to have sufficient power for this endpoint [3].
References:
1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Gomi H, Dervenis C, Windsor JA, Kim SW, de Santibanes E, Padbury R, Chen XP, Chan AC, Fan ST, Jagannath P, Mayumi T, Yoshida M, Miura F, Tsuyuguchi T, Itoi T, Supe AN; Tokyo Guideline Revision Committee. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:89-96.
2. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG; Tokyo Guidelines Revision Committee. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013;20:35-46.
3. Gurusamy KS, Nagendran M, Davidson BR. Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
Laparoscopic management of a type III Mirizzi syndrome: cholecystectomy with flag technique and ideal suture of a cholecystobiliary fistula
In this video, authors demonstrate the laparoscopic management of a Mirizzi syndrome. Due to a cholecystocholedochal fistula and to a difficult dissection of Calot’s triangle, authors decided to modify the dissection technique by performing a primary freeing of the gallblader as described by Jean Mouiel. In order to prevent any further biliary damage, a subtotal cholecystectomy is also achieved by means of an EndoGia™ linear stapler. Cholecystobiliary fistula is repaired using an absorbable running suture protected by an internal choledochal drain placed thanks to preoperative endoscopic catheterization.
HA Mercoli, L Marx, J Leroy, P Pessaux, J Marescaux
Surgical intervention
5 years ago
5992 views
176 likes
0 comments
07:11
Laparoscopic management of a type III Mirizzi syndrome: cholecystectomy with flag technique and ideal suture of a cholecystobiliary fistula
In this video, authors demonstrate the laparoscopic management of a Mirizzi syndrome. Due to a cholecystocholedochal fistula and to a difficult dissection of Calot’s triangle, authors decided to modify the dissection technique by performing a primary freeing of the gallblader as described by Jean Mouiel. In order to prevent any further biliary damage, a subtotal cholecystectomy is also achieved by means of an EndoGia™ linear stapler. Cholecystobiliary fistula is repaired using an absorbable running suture protected by an internal choledochal drain placed thanks to preoperative endoscopic catheterization.
Subtotal laparoscopic cholecystectomy for Mirizzi syndrome type IA
This video shows a case of Mirizzi syndrome type IA (according to the classification of Csendes and Nagakava). This 36-year-old female patient was admitted for an elective laparoscopic cholecystectomy due to a chronic calculous cholecystitis. Preoperative examination did not reveal any peculiarities. Patient set-up and trocar placement were conventional and unremarkable. During the operation, anatomical abnormalities of Calot’s triangle were observed -- namely common bile duct and other elements of the neck of gallbladder were not differentiated. The common bile duct was firstly adopted as the cystic duct, giving the impression that it falls into the gallbladder. In addition, it was impossible to visualize the proximal part of the common bile duct. After several long attempts at dissection, the cystic duct failed to show. We then opened the lumen of the gallbladder accidentally, which revealed the inner opening of the cystic duct. We used it as a landmark to dissect the stump of the cystic duct. Three Endoclips were applied onto the stump of the duct. The free wall of the gallbladder was excised. The remaining mucosa of the gallbladder was carefully coagulated.
In relation to such changes, the diagnosis of chronic calculous cholecystitis, Mirizzi syndrome type IA was established.
A Sazhin, S Mosin
Surgical intervention
5 years ago
4799 views
128 likes
0 comments
14:44
Subtotal laparoscopic cholecystectomy for Mirizzi syndrome type IA
This video shows a case of Mirizzi syndrome type IA (according to the classification of Csendes and Nagakava). This 36-year-old female patient was admitted for an elective laparoscopic cholecystectomy due to a chronic calculous cholecystitis. Preoperative examination did not reveal any peculiarities. Patient set-up and trocar placement were conventional and unremarkable. During the operation, anatomical abnormalities of Calot’s triangle were observed -- namely common bile duct and other elements of the neck of gallbladder were not differentiated. The common bile duct was firstly adopted as the cystic duct, giving the impression that it falls into the gallbladder. In addition, it was impossible to visualize the proximal part of the common bile duct. After several long attempts at dissection, the cystic duct failed to show. We then opened the lumen of the gallbladder accidentally, which revealed the inner opening of the cystic duct. We used it as a landmark to dissect the stump of the cystic duct. Three Endoclips were applied onto the stump of the duct. The free wall of the gallbladder was excised. The remaining mucosa of the gallbladder was carefully coagulated.
In relation to such changes, the diagnosis of chronic calculous cholecystitis, Mirizzi syndrome type IA was established.
Laparoscopic cholecystectomy in double gallbladder with dual pathology
Surgically significant anatomical variations are commonly encountered in cholecystectomies. Rarer though is double gallbladder. This anomaly adds more complexity to laparoscopy. The author presents a surgical video of laparoscopic cholecystectomy of a symptomatic young man with double gallbladder, highlighting the importance of preoperative diagnosis, meticulous dissection of the cholecysto-hepatic triangle, use of operative cholangiogram, and gentle blunt dissection near the porta hepatis as a recipe of success. Magnetic resonance cholangiopancreatography (MRCP) was suggestive of type 1 V-shaped gallbladder, with a short single cystic duct draining into the CBD. Operative cholangiogram showed one moiety containing the stones communicating with the CBD via a rather long cystic duct, while the other partially intrahepatic moiety was shown to be blind and non-communicating with either the CBD or its counterpart. The second gallbladder was in close proximity to the porta hepatis and to the right hepatic duct. Both gallbladders were supplied by a solitary cystic artery of significant size. Gentle blunt dissection by means of the suction cannula tip helped to dissect the second gallbladder from its intrahepatic position, safeguarding important porta hepatis structures. At the completion of surgery, both gallbladder fossas were carefully inspected to rule out any bile leak. Post-extraction dissection of the specimen showed a calculous cholecystitis in one piece and acalculous pyocele in the other piece, which was confirmed by histopathological examination.
S Ghosh
Surgical intervention
6 years ago
2376 views
16 likes
0 comments
13:23
Laparoscopic cholecystectomy in double gallbladder with dual pathology
Surgically significant anatomical variations are commonly encountered in cholecystectomies. Rarer though is double gallbladder. This anomaly adds more complexity to laparoscopy. The author presents a surgical video of laparoscopic cholecystectomy of a symptomatic young man with double gallbladder, highlighting the importance of preoperative diagnosis, meticulous dissection of the cholecysto-hepatic triangle, use of operative cholangiogram, and gentle blunt dissection near the porta hepatis as a recipe of success. Magnetic resonance cholangiopancreatography (MRCP) was suggestive of type 1 V-shaped gallbladder, with a short single cystic duct draining into the CBD. Operative cholangiogram showed one moiety containing the stones communicating with the CBD via a rather long cystic duct, while the other partially intrahepatic moiety was shown to be blind and non-communicating with either the CBD or its counterpart. The second gallbladder was in close proximity to the porta hepatis and to the right hepatic duct. Both gallbladders were supplied by a solitary cystic artery of significant size. Gentle blunt dissection by means of the suction cannula tip helped to dissect the second gallbladder from its intrahepatic position, safeguarding important porta hepatis structures. At the completion of surgery, both gallbladder fossas were carefully inspected to rule out any bile leak. Post-extraction dissection of the specimen showed a calculous cholecystitis in one piece and acalculous pyocele in the other piece, which was confirmed by histopathological examination.
Laparoscopic cholecystectomy 2 months after acute cholecystitis with intra-abdominal abscess
Cholecystectomy for symptomatic gallstones is mainly performed as soon as an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
Acute cholecystitis is generally caused by gallstones. Gallstones affect about 10% of the population in the Western world but over 80% of people with gallstones are asymptomatic. Acute cholecystitis develops in 1 to 3% of patients with symptomatic gallstones. Cholecystectomy can be performed by laparotomy or by laparoscopy, either at the time of the initial attack (early treatment) or 2 to 3 months after the initial attack has subsided (delayed treatment). A factor complicating the assessment of outcomes of early treatment is that “early” has been variably defined as anywhere from 24 hours to 5 days after either the onset of symptoms or the time of diagnosis. If a delayed or conservative treatment is selected, patients are treated during the acute phase with antibiotics, very occasionally patients undergo percutaneous cholecystostomy (placement of a tube in the gallbladder). Fifteen to 20% of patients who underwent delayed procedures had persistent or recurrent symptoms requiring intervention before the planned operation. Today early laparoscopic cholecystectomy is considered to be the treatment of choice for most patients.
L Marx, A D'Urso, D Mutter, J Marescaux
Surgical intervention
6 years ago
8307 views
119 likes
1 comment
07:53
Laparoscopic cholecystectomy 2 months after acute cholecystitis with intra-abdominal abscess
Cholecystectomy for symptomatic gallstones is mainly performed as soon as an acute cholecystitis episode settles. The main reason is the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis.
Acute cholecystitis is generally caused by gallstones. Gallstones affect about 10% of the population in the Western world but over 80% of people with gallstones are asymptomatic. Acute cholecystitis develops in 1 to 3% of patients with symptomatic gallstones. Cholecystectomy can be performed by laparotomy or by laparoscopy, either at the time of the initial attack (early treatment) or 2 to 3 months after the initial attack has subsided (delayed treatment). A factor complicating the assessment of outcomes of early treatment is that “early” has been variably defined as anywhere from 24 hours to 5 days after either the onset of symptoms or the time of diagnosis. If a delayed or conservative treatment is selected, patients are treated during the acute phase with antibiotics, very occasionally patients undergo percutaneous cholecystostomy (placement of a tube in the gallbladder). Fifteen to 20% of patients who underwent delayed procedures had persistent or recurrent symptoms requiring intervention before the planned operation. Today early laparoscopic cholecystectomy is considered to be the treatment of choice for most patients.
Laparoscopic management of Mirizzi syndrome
The surgical management of acute cholecystitis continues to be a matter of personal choice. At our institution, we perform early laparoscopic cholecystectomy electively after treatment with intravenous fluids and antibiotics.
We present the case of a 35-year-old man who was admitted with a history of pain in the right upper abdomen for one day. He was managed with analgesics, intravenous fluids, and antibiotics. Despite relief from pain with aggressive medical therapy, he developed jaundice. An ultrasound examination confirmed a small stone impacted in the neck of the gallbladder and non-dilated biliary radicles. In view of increased serum bilirubin, the patient was scheduled for laparoscopic cholecystectomy.
Laparoscopic cholecystectomy revealed a gangrenous gallbladder with dilated cystic and common bile ducts. Intraoperative cholangiogram showed a suspicious filling defect at the lower end of the common bile duct. The ureteric catheter was therefore left indwelling and removed after one month.
Aa Rai, R Singh, S Rai, Sa Rai
Surgical intervention
6 years ago
6283 views
102 likes
0 comments
16:58
Laparoscopic management of Mirizzi syndrome
The surgical management of acute cholecystitis continues to be a matter of personal choice. At our institution, we perform early laparoscopic cholecystectomy electively after treatment with intravenous fluids and antibiotics.
We present the case of a 35-year-old man who was admitted with a history of pain in the right upper abdomen for one day. He was managed with analgesics, intravenous fluids, and antibiotics. Despite relief from pain with aggressive medical therapy, he developed jaundice. An ultrasound examination confirmed a small stone impacted in the neck of the gallbladder and non-dilated biliary radicles. In view of increased serum bilirubin, the patient was scheduled for laparoscopic cholecystectomy.
Laparoscopic cholecystectomy revealed a gangrenous gallbladder with dilated cystic and common bile ducts. Intraoperative cholangiogram showed a suspicious filling defect at the lower end of the common bile duct. The ureteric catheter was therefore left indwelling and removed after one month.
Single stage laparoscopic management of common bile duct stones with acute cholecystitis
Ten to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP), open surgery, or laparoscopic surgery.
The first option depends mainly on the availability of an experienced endocopist who could successfully clear stones in most patients. However no stones are found in 20% to 60% of cases. In such patients, rare and unpredictably severe ERCP morbidity can occur.
Thanks to progress in laparosocopic techniques, associated with technological developments, the single stage laparoscopic management of CBD and gallbladder stones has become one of the main options for the treatement of choledocholithiasis associated with cholelithiasis.
After the analysis of local conditions and the interpretation of intraoperative cholangiography images it is fundamental to decide which type of access to use to get to the main biliary tract, either transcystic access or directly through choledochotomy.
J D'Agostino, J Marescaux
Surgical intervention
7 years ago
6444 views
64 likes
0 comments
06:11
Single stage laparoscopic management of common bile duct stones with acute cholecystitis
Ten to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP), open surgery, or laparoscopic surgery.
The first option depends mainly on the availability of an experienced endocopist who could successfully clear stones in most patients. However no stones are found in 20% to 60% of cases. In such patients, rare and unpredictably severe ERCP morbidity can occur.
Thanks to progress in laparosocopic techniques, associated with technological developments, the single stage laparoscopic management of CBD and gallbladder stones has become one of the main options for the treatement of choledocholithiasis associated with cholelithiasis.
After the analysis of local conditions and the interpretation of intraoperative cholangiography images it is fundamental to decide which type of access to use to get to the main biliary tract, either transcystic access or directly through choledochotomy.