A Type V Aberrant Right Hepatic Duct Branching from the Cystic Duct: The Paramount Importance of Intraoperative Cholangiography in Supplementing the Critical View of Safety Technique in Laparoscopic Cholecystectomy.

In this report, we present a 38-year-old female with acute cholecystitis, in which an aberrant right hepatic duct draining directly into the cystic duct was revealed by intraoperative cholangiography during a laparoscopic cholecystectomy. This anomaly was classified as the class V variant using the Hisatsugu classification schema, which has an incidence of 1.02%. The use of Strasberg's critical view of safety has become ubiquitous in laparoscopic cholecystectomy. Intraoperative cholangiography provides and additional layer of safety, and should be considered as a routine practice, particularly when imaging to delineate biliary anatomic aberrancies has not been performed prior to surgery.

Prospective randomized double-blind controlled trial of continuous local anesthetic infusion to reduce narcotic use in laparoscopic sleeve gastrectomy.

BACKGROUND: In an era of cost containment and outcome-based medicine, bariatric surgeons are attempting to decrease perioperative morbidity and streamline care. One way of accomplishing this is by decreasing opioid use and hospital stay. Several studies of nonbariatric open procedures have shown that continuous infusion catheters (CIC) are beneficial. Bariatric surgeons frequently utilize CIC, but the data is sparse for the clinical efficacy in laparoscopic procedures. OBJECTIVE: Evaluate the efficacy of CIC in laparoscopic sleeve gastrectomy. SETTING: military teaching hospital. METHODS: In this single institution prospective randomized double-blind controlled study, 82 patients undergoing laparoscopic sleeve gastrectomy (LSG) received either .2% ropivacaine or .9% normal saline (placebo) via CIC. After discharge, total narcotic usage, total antiemetic usage, pain scores, and hospital length of stay were evaluated. A one-way ANOVA was used to assess statistical significance. Power was 80% to detect 52 mg morphine equivalent difference. RESULTS: A total of 82 patients were enrolled, 39 received ropivacaine, and 43 received placebo. There was no statistically significant difference in narcotic usage between the ropivacaine group and placebo group, 51.9 mg versus 55.2 mg, respectively (P = .63). Ondansetron usage was 10.7 mg and 10.6 mg for ropivacaine and placebo groups. (P = .98). Average pain score was 3.0 for each group (P = .632). Total hospital length of stay was 37.5 hours for ropivacaine group and 38.1 hours for placebo group (P = .768). CONCLUSIONS: We found no difference in narcotic usage, antiemetic usage, pain scores, or hospital length of stay between ropivacaine and placebo groups. We conclude there is no utility of CIC in LSG.

Postoperative pneumoperitoneum on computed tomography: is the operation to blame?

BACKGROUND: Postoperative radiographs demonstrating pneumoperitoneum are a vexing problem for surgeons. This dilemma stems from uncertainty regarding the length of time for resolution of gas introduced operatively via either an open or a laparoscopic approach. We attempted to quantify the duration of pneumoperitoneum after both laparoscopic and open surgery in an animal model. METHODS: A prospective study using 2 groups of 10 pigs (Sus scrofa) was performed. The animals were assigned to undergo either an exploratory laparoscopy or an open abdominal exploration. Postoperatively, sequential computed tomography (CT) scans were performed to assess for the presence of pneumoperitoneum. RESULTS: Pneumoperitoneum resolution occurred sooner than average on CT scan in the laparoscopic group when compared to open group (1.79 days vs 4.73 days respectively; P value of .02). CONCLUSIONS: Postoperative pneumoperitoneum resolves more quickly after laparoscopy when compared to open surgery in the porcine model. This information may aid in evaluating postoperative CT scans demonstrating pneumoperitoneum.