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Laparoscopic cholecystectomy is a standard treatment for cholelithiasis. In situations where laparoscopic cholecystectomy is dangerous, a surgeon may be forced to change from laparoscopy to an open procedure. Data from the literature shows that 2 to 15% of laparoscopic cholecystectomies are converted to open surgery during surgery for various reasons. The aim of this study was to identify the risk factors for the conversion of laparoscopic cholecystectomy to open surgery. A retrospective analysis of medical records and operation protocols was performed. The study group consisted of 263 patients who were converted into open surgery during laparoscopic surgery, and 264 randomly selected patients in the control group. Conversion risk factors were assessed using logistic regression analysis that modeled the probability of a certain event as a function of independent factors. Statistically significant factors in the regression model with all explanatory variables were age, emergency treatment, acute cholecystitis, peritoneal adhesions, chronic cholecystitis, and inflammatory infiltration. The use of predictive risk assessments or nomograms can be the most helpful tool for risk stratification in a clinical scenario. With such predictive tools, clinicians can optimize care based on the known risk factors for the conversion, and patients can be better informed about the risks of their surgery.

Background Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC. Methods Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to “time-out” and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale. Results In the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 ( p  < 0.001). The number of videos with CVS score >4 increased from 15.7 to 52 % ( p  < 0.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7 %, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41–93 %, p  < 0.001) and offered appropriate bailout techniques (77–94 %, p  < 0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert score = 4.71, SD = 0.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σ  = 0.83). Conclusion The combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.

Preoperative anxiety and postoperative pain pose significant challenges in surgical settings, often leading to various physical and psychological complications. This study aimed to assess the impact of multimedia education on anxiety levels and pain among candidates undergoing laparoscopic cholecystectomy. In a clinical trial employing Solomon’s four-group design, 80 candidates for laparoscopic cholecystectomy were enrolled. They were selected through convenience sampling and randomly allocated to four groups: intervention group with pre-test (E1), intervention group without pre-test (E2), control group with pre-test (C1), and control group without pre-test (C2). Multimedia education was administered to the intervention groups. Data were collected using the State-Trait Anxiety Inventory (STAI) for anxiety assessment and the Visual Analog Scale (VAS) for pain measurement, then analyzed using SPSS-22 software. Preoperative state anxiety levels in groups E1 and E2 were significantly lower compared to C1 and C2 (38.6 ± 7.32, 38.1 ± 8.83, 46.3 ± 11.57, and 45.8 ± 9.57, respectively; p  = 0.006). However, there was no significant difference in state anxiety levels 24 h post-surgery nor in trait anxiety levels before and 24 h after surgery. Moreover, there was no significant difference in mean pain scores 24 h post-surgery among the groups. The findings indicate that multimedia education can effectively reduce preoperative anxiety in patients undergoing surgery. However, it did not significantly impact anxiety and pain levels post-surgery. Multimedia education may be considered as a supplementary approach to standard preoperative care protocols.

BackgroundIn minimally invasive surgery (MIS), trainees need to learn how to interpret the operative field displayed on the laparoscopic screen. Experts currently guide trainees mainly verbally during laparoscopic procedures. A newly developed telestration system with augmented reality (iSurgeon) allows the instructor to display hand gestures in real-time on the laparoscopic screen in augmented reality to provide visual expert guidance (telestration). This study analysed the effect of telestration guided instructions on gaze behaviour during MIS training.MethodsIn a randomized-controlled crossover study, 40 MIS naive medical students performed 8 laparoscopic tasks with telestration or with verbal instructions only. Pupil Core eye-tracking glasses were used to capture the instructor’s and trainees’ gazes. Gaze behaviour measures for tasks 1–7 were gaze latency, gaze convergence and collaborative gaze convergence. Performance measures included the number of errors in tasks 1–7 and trainee’s ratings in structured and standardized performance scores in task 8 (ex vivo porcine laparoscopic cholecystectomy).ResultsThere was a significant improvement 1–7 on gaze latency [F(1,39) = 762.5, p < 0.01, ηp2 = 0.95], gaze convergence [F(1,39) = 482.8, p < 0.01, ηp2 = 0.93] and collaborative gaze convergence [F(1,39) = 408.4, p < 0.01, ηp2 = 0.91] upon instruction with iSurgeon. The number of errors was significantly lower in tasks 1–7 (0.18 ± 0.56 vs. 1.94 ± 1.80, p < 0.01) and the score ratings for laparoscopic cholecystectomy were significantly higher with telestration (global OSATS: 29 ± 2.5 vs. 25 ± 5.5, p < 0.01; task-specific OSATS: 60 ± 3 vs. 50 ± 6, p < 0.01).ConclusionsTelestration with augmented reality successfully improved surgical performance. The trainee’s gaze behaviour was improved by reducing the time from instruction to fixation on targets and leading to a higher convergence of the instructor’s and the trainee’s gazes. Also, the convergence of trainee’s gaze and target areas increased with telestration. This confirms augmented reality-based telestration works by means of gaze guidance in MIS and could be used to improve training outcomes.

Background Different techniques have been proposed to reduce the incidence of the intraoperative bile duct injury during laparoscopic cholecystectomy (LC). Among these, Near-Infrared Fluorescence Cholangiography (NIFC) with Indocyanine Green (ICG) represents a relatively recent addition. At present, there is considerable variation in the protocols for the administration of ICG. Methods The aim of this randomized multicenter clinical trial (RCT) is to ascertain whether there are differences between the dosage and administration intervals of ICG, with a view to optimizing a good-quality NIFC during LC. Furthermore, an analysis was conducted to determine the potential impact of different factors on the outcomes of this technique. The trial was approved by the local institutional Ethics Committee. Results From June 2022 to June 2023, 200 patients were randomized in four arms (G1: 2.5 mg ICG > 3 h prior to surgery, G2: 2.5 mg ICG 15–30 min prior to surgery, G3: 0.05 mg/kg ICG > 3 h prior to surgery and G4: 0.05 mg/kg ICG 15–30 min prior to surgery). We found differences in the DISTURBED score between the groups ( p  < 0.001), suggesting that ICG administration 15–30 min before surgery was worse than administration > 3 h after LC ( p  = 0.02). Additionally, it was observed that body mass index (BMI), gender, ASA Classification System, previous liver and biliary disease and the type of surgery had influence on NIFC. Finally, the NIFC had an impact in intraoperative and postoperative complications, operative time and hospital length of stay. Conclusions The administration of ICG > 3 h improve liver background fluorescence in the NIFC during LC. There are different factors may affect NIFC results (BMI, ASA grade, previous liver disease, presence of gallbladder inflammation and type of surgery). Finally, high-quality NIFC was associated with fewer surgical complications, shorter surgical time and shorter length of hospital stay.

AbstractObjectiveTo assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis.DesignMulticentre, randomised controlled, superiority trial.Setting11 hospitals in the Netherlands, February 2011 to January 2016.Participants142 high risk patients with acute calculous cholecystitis were randomly allocated to laparoscopic cholecystectomy (n=66) or to percutaneous catheter drainage (n=68). High risk was defined as an acute physiological assessment and chronic health evaluation II (APACHE II) score of 7 or more.Main outcome measuresThe primary endpoints were death within one year and the occurrence of major complications, defined as infectious and cardiopulmonary complications within one month, need for reintervention (surgical, radiological, or endoscopic that had to be related to acute cholecystitis) within one year, or recurrent biliary disease within one year.ResultsThe trial was concluded early after a planned interim analysis. The rate of death did not differ between the laparoscopic cholecystectomy and percutaneous catheter drainage group (3% v 9%, P=0.27), but major complications occurred in eight of 66 patients (12%) assigned to cholecystectomy and in 44 of 68 patients (65%) assigned to percutaneous drainage (risk ratio 0.19, 95% confidence interval 0.10 to 0.37; P<0.001). In the drainage group 45 patients (66%) required a reintervention compared with eight patients (12%) in the cholecystectomy group (P<0.001). Recurrent biliary disease occurred more often in the percutaneous drainage group (53% v 5%, P<0.001), and the median length of hospital stay was longer (9 days v 5 days, P<0.001).ConclusionLaparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis.Trial registrationDutch Trial Register NTR2666.

ObjectiveTo test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions.Summary background dataIn LC, biliary injury and conversion often happen if the biliary anatomy is misidentified.MethodsThis was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures.ResultsTotally 92 patients participated (46 patients in each arm). The median age was 61 years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16–1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5 min in the conventional arm and 149.5 min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380).ConclusionICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct.Trial registrationThe trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster (http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics). Registration number: UW17-492.

BackgroundAlthough single-port laparoscopic cholecystectomy (SILC) is safe and effective, inherent surgeons’ discomfort has prevented a large-scale adaptation of this technique. Recent advances in robotic technology suggest that da Vinci Single-Site™ cholecystectomy (dVSSC) may overcome this issue by reducing the stress load of the surgeon compared to SILC. However, evidence to objectively assess differences between the two approaches is lacking.Methods60 patients [36 women, 24 men (mean age 52 years)] with benign gallbladder disease were randomly assigned to dVSSC (n = 30) or SILC (n = 30) in this single-centre, single-blinded controlled trial. The primary endpoint was surgeon’s stress load. Secondary endpoints included operating time, conversion rates, additional trocar placement, blood loss, length of hospital stay, procedure costs, health-related quality of life, cosmesis and complications. Data were collected preoperatively, during the hospital stay, and at 1 and 12 months’ follow-up.ResultsThe dVSSC group showed a significant reduction of mental stress load of the surgeon compared to SILC [Subjective Mental Effort Questionnaire (SMEQ) score: median 25.0 (range 8–89) vs. 42.5 (range 13–110) points; p = 0.002] and a trend towards reduced physical stress load [Local Experienced Discomfort (LED) score: median 8 (range 2–27) vs. 12 (range 0–64) points; p = 0.088]. The length of hospital stay was longer in the SILC group [mean 3.06 (median 2; range 1–26) vs. 1.9 (median 2; range 1–4) days, p = 0.034] but overall hospital costs were higher for dVSSC [median 9734 (range 5775–16729) vs. 6900 (range 4156–99977) CHF; p = 0.001]. There were no differences in the rate of postoperative complications that required re-intervention (Dindo–Clavien grade ≥ IIIa; SILC n = 2 vs. dVSSC n = 0, p = 0.492) or other secondary endpoints.ConclusionsDa Vinci Single-Site™ cholecystectomy provides significant benefits over Single-Port Laparoscopic Cholecystectomy in terms of surgeon’s stress load, matches the standards of the laparoscopic single-incision approach with regard to patients’ outcomes but increases expenses. Clinicaltrials.gov registration-No.: NCT02485392.

Background Patients with prior abdominal surgeries are at higher risk of intra-peritoneal adhesions near the trocar entry site, increasing the likelihood of organ injury during laparoscopic cholecystectomy (LC). This study evaluates a novel technique where the epigastric trocar is inserted first, after creating pneumoperitoneum, to allow safe dissection of adhesions under direct vision before placing the umbilical trocar. Methods This prospective study included 244 patients with symptomatic uncomplicated gallstone disease and a history of previous abdominal surgeries extending to the umbilicus. Patients were randomly assigned to two groups: Group I ( n  = 98) underwent traditional umbilical trocar-first LC using the Hasson technique, while Group II ( n  = 146) received LC using the epigastric trocar-first approach. Operative time, complications, and conversion rates were analyzed. Results There was no significant difference in the demographics between both groups. The epigastric trocar-first approach significantly reduced total operative time (41.6 ± 7.7 min vs. 46.8 ± 8.8 min, p  = 0.031) and small bowel injury rates ( p  = 0.006). Otherwise, intraoperative complications were comparable. Conversion to open surgery was lower in Group II (2.1% vs. 8.2%, p  = 0.012). Postoperative pain at 6 h was significantly lower in Group II ( p  = 0.001). Conclusions The epigastric trocar-first approach, offers a safer alternative for patients with prior abdominal surgeries when undergoing LC. This approach is safe; minimizes bowel injury risk, reduces conversion rates, and enhances patient recovery. This approach may also be beneficial in other laparoscopic procedures requiring safe entry in patients with prior abdominal surgeries. Further studies are recommended to validate its broader clinical application.

Background Randomized studies could not demonstrate significant outcome benefit after single-incision laparoscopic cholecystectomy compared to classic four-port laparoscopic cholecystectomy (CLC). The new robotic single-site platform might offer potential benefits on local inflammation and postoperative pain due to its technological advantages. This prospective randomized double-blind trial compared the short-term outcomes between single-incision robotic cholecystectomy (SIRC) and CLC. Methods Two groups of 30 eligible patients were randomized for SIRC or CLC. During the first postoperative week, patients and study monitors were blinded to the type of procedure performed by four dressing tapes applied on the abdomen. Pain was assessed at 6 h and on day 1, 7 and 30 after surgery, along with a 1–10 cosmetic score. Results No significant difference in postoperative pain occurred in the two groups at any time point nor for any of the abdominal sites. Nineteen (63 %) SIRC patients reported early postoperative pain in extra-umbilical sites. Intraoperative complications which might influence postoperative pain, such as minor bleeding and bile spillage, were similar in both groups and no conversions occurred. The cosmetic score 1 month postoperatively was higher for SIRC ( p  < 0.001). Two SIRC patients had wound infection, one of which developed an incisional hernia. Conclusions SIRC does not offer any significant reduction of postoperative pain compared to CLC. SIRC patients unaware of their type of operation still report pain in extra-umbilical sites like after CLC. The cosmetic advantage of SIRC should be balanced against an increased risk of incisional hernias and higher costs. Trial registration number ACTRN12614000119695 ( http://www.anzctr.org.au ).