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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
2433 views
17 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 management of sealed gallbladder perforation
This video features a 62-year-old diabetic male patient who is not undergoing any treatment. He has sufferont from vague upper abdominal pain for one month. He has a past history of acute upper abdominal pain which was managed conservatively.
Abdominal ultrasonography demonstrates cholelithiasis with signs of chronic cholecystitis. Blood examination reveals hyperglycemia with normal liver function tests.
After controlling the hyperglycemic status, the patient is subjected to a laparoscopic cholecystectomy. There is evidence of gallbladder perforation, as the gallbladder is sealed off by the omentum. The gallbladder presents a large amount of calculi which are visible through the thin wall of the gallbladder, and some calculi almost protruding out through the wall.
The laparoscopic cholecystectomy is performed successfully with caution not to soil the peritoneum.
E Khiangte, I Newme, P Phukan
Surgical intervention
8 years ago
4061 views
53 likes
0 comments
06:39
Laparoscopic management of sealed gallbladder perforation
This video features a 62-year-old diabetic male patient who is not undergoing any treatment. He has sufferont from vague upper abdominal pain for one month. He has a past history of acute upper abdominal pain which was managed conservatively.
Abdominal ultrasonography demonstrates cholelithiasis with signs of chronic cholecystitis. Blood examination reveals hyperglycemia with normal liver function tests.
After controlling the hyperglycemic status, the patient is subjected to a laparoscopic cholecystectomy. There is evidence of gallbladder perforation, as the gallbladder is sealed off by the omentum. The gallbladder presents a large amount of calculi which are visible through the thin wall of the gallbladder, and some calculi almost protruding out through the wall.
The laparoscopic cholecystectomy is performed successfully with caution not to soil the peritoneum.
Addressing the challenges of a complicated laparoscopic cholecystectomy for cholecystitis: a live educational procedure
In this live educational video, Professor Didier Mutter provides a precise description of the most important anatomical landmarks related to cholecystectomy performed for cholecystitis. The video features a noteworthy case of fibrotic gallbladder surrounded by inflammation managed with cholecystectomy. In spite of anatomical difficulties, Professor Mutter shows how to perform a "critical view of safety", the systematization of which should be dogmatic, with complete extraction of all gallstones, in the learning process of cholecystectomy.
The author performs an outstanding standardized surgery, explaining the techniques and maneuvers to be performed in order to obtain success.
D Mutter, R Canales Cama, J Marescaux
Surgical intervention
1 month ago
3439 views
31 likes
18 comments
41:41
Addressing the challenges of a complicated laparoscopic cholecystectomy for cholecystitis: a live educational procedure
In this live educational video, Professor Didier Mutter provides a precise description of the most important anatomical landmarks related to cholecystectomy performed for cholecystitis. The video features a noteworthy case of fibrotic gallbladder surrounded by inflammation managed with cholecystectomy. In spite of anatomical difficulties, Professor Mutter shows how to perform a "critical view of safety", the systematization of which should be dogmatic, with complete extraction of all gallstones, in the learning process of cholecystectomy.
The author performs an outstanding standardized surgery, explaining the techniques and maneuvers to be performed in order to obtain success.
How fluorescence can help to obtain the critical view of safety (CVS) during laparoscopic cholecystectomy: a live educational procedure broadcasted from IRCAD Taiwan
This live educational video broadcasted from IRCAD Taiwan shows the case of a 31-year-old woman admitted to hospital for chronic abdominal pain in the right upper quadrant for one month. Ultrasonography (US) demonstrated gallstones with a moderate thickening of the gallbladder wall. The patient had a BMI of 26 and she had a past surgical history of laparotomy for perforated appendicitis and thyroidectomy for papillary cancer.
This procedure highlights the benefits of intraoperative guidance with ICG fluorescence. In addition to a conventional preoperative intravenous (IV) injection, ICG fluorescence was used intraoperatively to understand and demonstrate the vascular anatomy of the hepatocystic triangle. During this procedure, technical points are discussed between Dr. M Lin, the operator, and Drs. B Dallemagne, HP Wong, W Huang.
M Lin, B Dallemagne, HP Wong, W Huang, A Garcia
Surgical intervention
17 days ago
594 views
9 likes
1 comment
20:59
How fluorescence can help to obtain the critical view of safety (CVS) during laparoscopic cholecystectomy: a live educational procedure broadcasted from IRCAD Taiwan
This live educational video broadcasted from IRCAD Taiwan shows the case of a 31-year-old woman admitted to hospital for chronic abdominal pain in the right upper quadrant for one month. Ultrasonography (US) demonstrated gallstones with a moderate thickening of the gallbladder wall. The patient had a BMI of 26 and she had a past surgical history of laparotomy for perforated appendicitis and thyroidectomy for papillary cancer.
This procedure highlights the benefits of intraoperative guidance with ICG fluorescence. In addition to a conventional preoperative intravenous (IV) injection, ICG fluorescence was used intraoperatively to understand and demonstrate the vascular anatomy of the hepatocystic triangle. During this procedure, technical points are discussed between Dr. M Lin, the operator, and Drs. B Dallemagne, HP Wong, W Huang.
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
1 year ago
584 views
9 likes
2 comments
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
1 year ago
25181 views
208 likes
20 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
1 year ago
25162 views
208 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.
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
3 years ago
2106 views
162 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 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
7445 views
882 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.
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
5 years ago
3719 views
129 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 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
5678 views
294 likes
1 comment
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
4 years ago
1231 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.