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RESUMEN Antecedentes: el uso de la colangiografía intraoperatoria dinámica (CIOd) durante la colecistectomía laparoscópica (Colelap) sigue siendo un tema en discusión. Objetivos: Este trabajo tiene como objetivo describir y evaluar la curva de aprendizaje y los hallazgos en la CIOd durante las colecistectomías laparoscópicas realizadas por residentes de Cirugía General, incluyéndola como herramienta para una colecistectomía segura, así como entrenamiento para el de sarrollo de habilidades y destrezas. Material y métodos: se incluyeron pacientes con indicación de colecistectomía laparoscópica pro gramada o de urgencia. En las cirugías se realizó tracción según Hunter, visión crítica de seguridad y CIOd sistemática, por un residente mayor y la CIOd por un residente inferior, tutorizado por cirujano de planta. Se evaluaron curva de aprendizaje, tiempos operatorios, relación del tiempo de CIOd con el tiempo de duración de la Colelap (CIO/CX), redisección del cístico y litiasis cística y coledociana. Resultados: se operaron 456 pacientes durante un año (2017-2018). Se observó que, independiente mente de quien realice la CIOd, los residentes pudieron mejorar su curva de aprendizaje, objetiván dose tiempos más cortos para la Colelap, CIOd y la relación CIO/CX. Los coeficientes de aprendizaje fueron mejores en cirugías más complejas en relación con el semestre. El 5,26% presentó litiasis cole dociana (n = 24); de estas, 66,7% tenían litiasis cística (n = 16) y 25% colecistitis (n = 6) asociadas. Todas se resolvieron por vía transcística. No hubo conversiones y se realizó CIOd en el 100%. Conclusión: la CIOd es un procedimiento ideal para ser practicado de manera sistemática durante la Residencia, porque da el entrenamiento necesario para el manejo de la vía transcística, permite evitar una lesión quirúrgica de vía biliar mayor y el diagnóstico de coledocolitiasis.
ABSTRACT Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.
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Humans , Male , Female , Adolescent , Adult , Middle Aged , Young Adult , Cholangiography/psychology , Learning Curve , Medical Staff, Hospital/psychology , General Surgery/education , Epidemiology, Descriptive , Prospective Studies , Cholecystectomy, Laparoscopic/psychology , Internship and ResidencyABSTRACT
Objective To investigate the application value of Calot triangle hollowing-out maneuver in laparoscopic cholecystectomy (LC) for preventing bile duct injury.Methods The retrospective cross-sectional study was conducted.The clinical data of 537 patients who underwent LC in the Dexing People's Hospital between January 2011 and December 2015 were collected.The tissues in Calot triangle were hollowed out,and cystic ducts were cut off and then gall bladders were resected.Observation indicators:(1) operation situations:anatomy of the Calot triangle and operation time;(2) postoperative recovery situations:postoperative complications and bile duct injury;(3) follow-up situation.The follow-up using outpatient examination and telephone interview was performed to detect the survival of patients and occurrence of cholangitis up to May 2016.Results (1) Operation situations:of 537 patients with LC,anatomical relation among cystic duct,common hepatic duct and common bile duct (three-duct relation for short) could be seen in 165 patients without dissection,and three-duct relation cannot be seen in other 372 patients.Of 372 patients,16 were operated on with the gallbladder open due to the difficult dissection of Calot triangle,7 were converted to open surgery due to local severe adhesion and unclear structure,1 was converted to open surgery due to intraoperative varices induced bleeding in Calot triangle,and other 348 patients underwent successful LC using Calot triangle hollowing-out maneuver.Operation time was 15-190 minutes,with an average time of 28 minutes.(2) Postoperative situations:2 patients were complicated with biliary colic pain,showing stones in the distal common bile duct via magnetic resonance imaging scans,and then received endoscopic sphincterotomy (EST);3 had subxyphoid puncture hole infection,1 had a small amount of postoperative bleeding due to hepatocirrhosis,3 had pulmonary infection,and they were improved by symptomatic treatment;1 had chylous fistula and were improved through drainage and low fat diet intake for 1 week;2 with mild bile leakage was improved through peritoneal drainage.No bile duct injury was detected.(3) Follow-up situation:348 patients were followed up for 12-18 months,with a median time of 16 months.During the followup,348 patients with follow-up had survival without manifestation of cholangitis.Conclusion Calot triangle hollowing-out maneuver could effectively prevent bile duct injury in LC.
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El conocimiento de la anatomía de la vía biliar y sus variantes para la realización de una cirugía segura, resulta fundamental. La extirpación de la vesícula requiere cuidadosa atención, conocer muy bien la anatomía de la región, teniendo en cuenta la posibilidad de variaciones anatómicas. La mala interpretación de la anatomía percibida más que una falta en la destreza técnica es la causa de la lesión de la vía biliar durante la colecistectomía. Diferenciar el límite y el contenido del trígono cistohepático. Diseñar las áreas de Visión Crítica y de Seguridad como medida de seguridad en el paciente quirúrgico. Revisión de 458 partes quirúrgicos de colecistectomías de enero/2010 a octubre/2012, en el Servicio de Cirugía General del Hospital Aeronáutico Central, y disección de 12 cadáveres adultos formolizados al 10% en la III Cátedra de Anatomía - Facultad de Medicina - Universidad de Buenos Aires. De 458 colecistectomías, se clasificaron los partes quirúrgicos, dividiéndose según menciona: triángulo de Calot en 247 (53,93%); triángulo hepatocístico en 59 (12,88%); área de visión crítica en 152 (33,18%); ninguno mencionó al triángulo de Budde o trígono cistohepático. Se disecaron 12 cadáveres adultos donde se identificó: arteria cística originándose de arteria hepática derecha en 9 (75%); originándose de arteria hepática izquierda en 2 (16,66%) y originándose de arteria hepática en 1 (8,34%). En 7 (58,35%) se la visualiza en trígono cistohepático. El conocimiento de la anatomía de la vía biliar y sus variantes para la realización de una cirugía segura, resulta fundamental. El triángulo descrito por Calot corresponde a la mitad inferior del triángulo descrito por Buddé. El sector lateral (Triangulo de Seguridad) es el verdadero área de visión critica a disecar por la menor probabilidad de lesionar estructuras nobles.
Knowing the anatomy of the bile duct and its anatomical variations becomes essential to safely perform any surgery. Gallbladder resection requires careful attention: knowing the region's anatomy by heart and taking into account the possibility of anatomical variations. Misunderstanding the anatomy is not only a failure in technical ability but also a cause of injury to the bile duct during a cholescystectomy. The objectives of this study were, to distinguish the boundaries and content of the trigonum cystohepaticum. Furthermore, to design the areas of Safety and Critical Vision as a safety measure for the patient undergoing surgery. Analysis of 458 surgical reports on cholecystectomies performed from January 2010 to October 2012 by the Hospital Aeronáutico's General Surgery Department, and dissection of 12 adult cadavers preserved in a 10% formalin solution at the IIIrd Chair of Anatomy, School of Medicine, University of Buenos Aires. From 458 cholecystectomies, surgical reports were classified as mentioning: Calot triangle, 247 (53.93%); cystohepatic triangle, 59 (12.88%); critical vision area, 152 (33.18%). None of them mentioned Buddé triangle or trigonum cystohepaticum. Twelve adult cadavers were dissected in which we identified the cystic artery: originating from right hepatic artery, 9 (75%); originating from left hepatic artery, 2 (16.66%); and originating from hepatic artery, 1 (8.34%). Trigonum cystohepaticum is observed in 7 cadavers (58.35%). Knowing the anatomy of the bile duct and its anatomical variations becomes essential to safely perform any surgery. The triangle described by Calot is the lower half of the triangle described by Buddé. The lateral portion (Safety Triangle) is the area of critical vision to be dissected due to the lower probability of injuring noble structures.
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Humans , Male , Female , Adult , Cholecystectomy , Cystic Duct/anatomy & histology , Anatomic Variation , Hepatic Duct, Common/anatomy & histology , Liver/anatomy & histology , Medical Errors/prevention & control , Gallbladder/anatomy & histology , Gallbladder/surgeryABSTRACT
Double gallbladder is one of the rare congenital anomalies of the gallbladder. Failure to detect an accessory gallbladder hampers diagnosis and treatment of cholecystitis, which might result in recurrent attacks of cholecystitis. In addition, presence of peritoneal folds extending from the stomach and duodenum to the gallbladder is very rare. Here we report the presence of a double gallbladder enclosed in a cystogastric fold of the peritoneum. During cadaveric dissection, we observed a cystogastric peritoneal fold that extended from the lesser curvature of the stomach and the first part of the duodenum to the gallbladder. The left end of the peritoneal fold merged with the lesser omentum. It enclosed two gallbladders: the main gallbladder and a small accessory gallbladder. The accessory gallbladder was a small pouch with its fundus attached to the main gallbladder by fibrous tissue, and its duct opened into the main cystic duct.
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Cadaver , Cholecystitis , Cystic Duct , Diagnosis , Duodenum , Gallbladder , Omentum , Peritoneum , StomachABSTRACT
Double gallbladder is one of the rare congenital anomalies of the gallbladder. Failure to detect an accessory gallbladder hampers diagnosis and treatment of cholecystitis, which might result in recurrent attacks of cholecystitis. In addition, presence of peritoneal folds extending from the stomach and duodenum to the gallbladder is very rare. Here we report the presence of a double gallbladder enclosed in a cystogastric fold of the peritoneum. During cadaveric dissection, we observed a cystogastric peritoneal fold that extended from the lesser curvature of the stomach and the first part of the duodenum to the gallbladder. The left end of the peritoneal fold merged with the lesser omentum. It enclosed two gallbladders: the main gallbladder and a small accessory gallbladder. The accessory gallbladder was a small pouch with its fundus attached to the main gallbladder by fibrous tissue, and its duct opened into the main cystic duct.
Subject(s)
Cadaver , Cholecystitis , Cystic Duct , Diagnosis , Duodenum , Gallbladder , Omentum , Peritoneum , StomachABSTRACT
Objective To explore the feasibility of tubular model based segmentation method for cystic artery and three-dimensional (3D) reconstruction model of Calot's triangle.Methods A tubular model based 3D region growing algorithm was proposed for the segmentation of cystic arteries and its adjacent vessels from 13 patients' CT images in DICOM format.The data was transferred to 3D visualization workstation based on a set of CalotShow1.0 software for 3D reconstruction.Results The method could effectively segment cystic artery and obtain the 3D model of Calot's triangle.Conclusions The 3D reconstruction model based on tubular model related vessel segmentation method and CalotShow1.0 can accurately display the spatial positions and adjacent relationships of cystic artery and Calot's triangle.
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Objetivo: Revisar el manejo terapéutico, según el tipo de lesiones, ubicación de acuerdo a la clasificación de Strasberg's Bismuth, y según el momento en que se realiza el diagnóstico. Métodos: Se presentan 5 casos con lesiones iatrogénicas de la vía biliar, en un total de 411 colecistectomías en el Hospital José María Benítez, desde enero 2008 a octubre 2013, en las cuales se realizó tratamiento quirúrgico y/o endoscópico según el caso. Estudio descriptivo y retrospectivo. Resultados: De los 5 pacientes, presentados 4 pertenecen al Hospital José María Benítez y uno fue referido de otro centro asistencial, total de 411 colecistectomías, abiertas 310, laparoscópicas 101. La incidencia en colecistectomía abierta 0,97% (3/309) y en colecistectomía por laparoscopia 0,99% (1/101). La resolución se realizó en 4 casos con tratamiento quirúrgico y en 1 caso con tratamiento endoscópico, esfinterotomía más stent biliar. Evolución post-operatoria sin complicaciones. Conclusión: Las lesiones iatrogénicas de la vía biliar principal son situaciones clínicas complejas con importante morbilidad,generando complicaciones agudas o crónicas afectando severa-mente la calidad de vida en el mejor de los casos, en su gran mayoría se producen durante colecistectomías y se considera que son el resultado de una identificación incorrecta de los elementos del triángulo de Calot. Una vez que se presentan se requiere de un abordaje integral y de un equipo entrenado multidisciplinario entre cirujanos, radiólogos, y endoscopistas(AU)
Objective: To review the therapeutic, depending on the typeof injury management, location according to the classification of Strasberg's - Bismuth, and according to the moment in which the diagnosis is made. Methods: Five cases with iatrogenic injuries of the biliary tract, of 411 cholecystectomies in the Hospital José María Benítez since January 2008 to October 2013, which was carried out surgical or endoscopic treatment according to the case are presented. It's a descriptive and retrospective study.Results: Of the 5 patients presented, 4 belong to the Hospital José María Benítez and one was referred to other healthcare, total 411 cholecystectomies: open 310, laparoscopic 101. The incidence in open cholecystectomy 0.97% (3/309) and laparoscopic 0.99% (1/101). The resolution was carried out in 4 cases with surgical treatment and in 1 case with endoscopic treatment, sphincterotomy plus biliary stent. Postoperative evolution was without complications. Conclusion: The main bile duct iatrogenic injuries are complex clinical situations with significant morbidity, generating acute or chronic complications, severely affecting the quality of life in the best of cases, the vast majority occur during cholecystectomies andit is considered to be the result of an incorrect identification of the elements of Calot's triangle. Once presented, requires a comprehensive approach and a trained multidisciplinary team between surgeons, radiologists, and endoscopists(AU)
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Humans , Male , Female , Adult , Aged , Bile Ducts , Cholecystectomy , Cholecystectomy, Laparoscopic , Diagnosis , Postoperative Care , Morbidity , Laparoscopy , Surgeons , HospitalsABSTRACT
Background: The knowledge of variations in the origin and course of cystic artery is important for the surgeons as uncontrolled bleeding from the cystic artery and its branches can be fatal during cholecystectomy. Intra operative bleeding can result in an increase in the risk of intra operative injury to vital vascular and biliary structures. Keeping in view the clinical significance and applied importance of the cystic artery anatomy and to add some more knowledge to the existing ones, the present study was undertaken, to know in detail the level of origin, length, and variations in the course and relation of the cystic artery. Methods: The present study was performed on 100 human liver specimens with intact gallbladder and extrahepatic duct system, obtained after dissection from the cadavers in the Department of Anatomy and from post-mortem cases from the Department of Forensic Medicine, Mysore Medical College and Research Institute, Mysore, over a period of 18 months. Results: Most common source of origin of the cystic artery was the right hepatic artery in 92 cases (92%) followed by aberrant right hepatic artery in 4 cases (4%) and the least common sources observed were the left hepatic artery in 1 case (1%) and the gastroduodenal artery in 1 case (1%).Mean length of the cystic artery was 17.6 mm and ranged between 3.7 mm to 42 mm. Out of the 100 dissected specimens, in 65 (65%) the cystic artery was found inside the Calot’s triangle and in 35 (35%) outside the triangle. Conclusion: This study provides details of the normal as well as the variant anatomy of the cystic artery, knowledge of which is very essential for the surgeons to minimize the risk of injury to the blood vessels and the biliary apparatus during cholecystectomy.
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Cystic artery is usually a branch of right hepatic artery given in the Calot’s triangle. Variations in the origin of cystic artery have been reported but there is paucity of literature regarding these in Indian subjects. The present case describes the origin of cystic artery from the hepatic artery proper, with an unusual course, which was detected during routine cadaveric dissection. The development of biliary vasculature is quite complex and it accounts for many variations. Knowledge of cystic artery variability facilitates intraoperative identification of vessels in both classical and laparoscopic surgery of the bile ducts. This emphasises the importance of a thorough knowledge of the cystic arterial variations that often occur and may be encountered during both laparoscopic and open cholecystectomy. Uncontrolled bleeding from the cystic artery and its branches is a serious problem that may increase the risk of intraoperative lesions to vital vascular and biliary structures during hepatobiliary surgery.
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Vascular variations in and around the porta hepatis are common. A sound knowledge of possible variations at these sites is vital for surgeons during laparoscopic cholecystectomy and surgical resection of the liver lobes. We report the case of several variations of the hepatic and cystic arteries in which, the common hepatic artery trifurcated into the gastroduodenal, right hepatic, and left hepatic arteries. The right gastric artery arose from the left hepatic artery and divided into a left and a right branch. The left branch entered the liver through the porta hepatis, while the right branch passed behind the common hepatic duct into the Calot's triangle, provided 2 branches to the gallbladder, and continued to supply the right hepatic lobe. Ligation of the right branch of the right hepatic artery in Calot's triangle during cholecystectomy could cause avascular necrosis of the liver segments it supplies.
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Arteries , Cholecystectomy , Cholecystectomy, Laparoscopic , Equipment and Supplies , Gallbladder , Hepatic Artery , Hepatic Duct, Common , Ligation , Liver , NecrosisABSTRACT
Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy and postoperative complications are still inevitable in certain cases. Knowledge of the rate and underlying reasons for conversion and postoperative complications could help surgeons during preoperative assessment and improve the informed consent of patients. We decide to review the rate and causes of conversion and postoperative complications of our LC series. This study included 760 consecutive laparoscopic cholecystectomies from July 2006 to June 2011 at Faridpur Central Hospital and Faridpur Medical College Hospital. All patients had surgery performed by same surgeon. Conversion to open cholecystectomy required in 19 (2.5%) patients. The most common reasons for conversion were severe adhesions at calot's triangle (6, 0.83%) and acutely inflamed gallbladder (5, 0.66%). The incidence of postoperative complications was 1.58%. The most common complication was wound infection, which was seen in 5 (0.66%) patients followed by biliary leakage in 3 (0.40%) patients. Delayed complications seen in our series is port site incisional hernia (2, 0.26%). LC is the preferred method even in difficult cases. Our study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands, the surgeons should keep a low threshold for conversion to open surgery and it should not be taken as a step in the interest of the patient rather than be looked upon as an insult to the surgeon.
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Objective To study the clinical application value of aspirator and electrocautery in dissecting Calot′s triangle in laparoscopic cholecystectomy(LC).Methods All patients underwent LC were divided into group A and group B according the detaching way in the operation.The Calot′s triangle were detached by electrocautery as group A and by aspirator as group B.Operative time,hemorrhage and complication between two groups were compared.Results The mean operative time was(28.5?7.6) minutes in group A and(21.1?4.3) minutes in group B.The mean hemorrhage was(13.9?(4.7)) ml in group A and(8.8?2.5) ml in group B.The complication of bile duct injury occurred in 2 cases in group A.No complication was found during or after surgery in group B.All patients were cured.Conclusion Aspirator and electrocautery are both suitable for skeletonizing the cystic duct and cystic artery in LC.
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Objective To summarize the anatomical variations of the Calot's triangle and explore the best method to manage the variations during laparoscopic cholecystectomy(LC).Methods From December 2006 to December 2008,158 patients with anatomical variation of the Calot's triangle received LC,the clinical data of the cases were reviewed retrospectively.Results Among the cases,15 patients were converted to open surgery because of Ⅰ type Mirizzi syndrome(3 cases),Ⅱ type Mirizzi syndrome(4 cases),low location of the convergence of the cystic duct and the common bile duct(2 cases),cystic duct opening into the posterior wall of the common bile duct(2 cases),the cystic duct and common bile duct sharing 2-cm lateral wall(1 case),severe adhesion of the Calot's triangle(2 cases),and hemorrhage of the posterior cystic artery(1 case).The LC were completed in 143 patients,among which 5 cases had postoperative complications,including biliary leakage in 1 case(cured by a second operation),bleeding at the puncture sites in 2 patients,infection of the puncture site in 1 case,and residual cystic stones in 1 case(cured by ERCP in 2 weeks).Conclusions Knowledge of the anatomical variations of the Calot's triangle is the key to LC.Different surgical strategies should be carried out according to the dissection of the Calot's Triangle area,and the location of the common hepatic duct and common bile duct.
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Objective To study a safe method to dissect cystic duct under laparoscope. Methods Clinical data of 300 cases of posterior Calot's triangle approach laparoscopic cholecystectomy (LC) from November 2000 to April 2003 were analyzed respectively. Results Posterior Calot's triangle approach LC was successfully carried out in 282 cases while a conversion to open surgery was required in 18 cases (6%, 18/300). Postoperative complications were observed in 2 cases (0.7%, 2/300). Conclusions Posterior Calot's triangle approach LC is a safe procedure and simple to operate.
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This paper reports 6 cases of cholecystitis with cholelithiasis whose calot triangles were thickened and hardened by fibrous tissue among 200 cases treated by laparoscopic cholecystectomy (L. C). The condition is different from common pathological adhesion by replacement of the structures in the calot triangle by hardened and contracted lumpish mass,and the normal anatomy disappears. LC in such condition is very difficult. Three patients were transfered to laparotomy. Three other patients underwent LC after a special effort which required a time comsuming process. The authors suggest that a special term as "Calot Triangle Lumpish Fibrosis" shpuld be given to this special condition and suggest that it is a relative contraindication for LC.