Single stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography for cholecysto-choledocholithiasis. Lesson learnt from the COVID-19 pandemic.

Introduction: Choledocholithiasis, a common complication of gallstone disease, poses significant risks including cholangitis and pancreatitis. Various treatment approaches exist, including single-stage and two-stage techniques, with recent literature suggesting advantages of the single-stage approach in terms of outcomes and cost-effectiveness. This study evaluates the feasibility, efficacy, and safety of single-stage laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC + iERCP) compared to the previously adopted two-stage approach. Methods: A retrospective analysis was conducted on patients undergoing single-stage LC + iERCP for cholecysto-choledocholithiasis during the COVID-19 pandemic (2020-2022). Data on demographics, preoperative assessments, intraoperative parameters, and postoperative outcomes were collected and compared with an historical control group undergoing the two-stage approach (LC + preopERCP). Hospitalization costs were also compared between the two groups. Results: A total of 190 patients were included, with 105 undergoing single-stage LC + iERCP. The single-stage approach demonstrated successful completion without cystic duct cannulation, with no conversions to open surgery. Operative time was comparable to the two-stage approach, while hospital stay, and costs were significantly lower in the single-stage group. Complication rates were similar between the groups. Conclusions: Single-stage LC + iERCP appears to be a feasible, effective, and safe approach for treating cholecysto-choledocholithiasis, offering potential benefits in terms of reduced hospital stay, OR occupation time, and costs compared to the two-stage approach. Integration of this approach into clinical practice warrants consideration, unless there are logistical challenges that cannot be overcome or lack of endoscopic expertise also for treating challenging urgent cases.

Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents.

OBJECTIVE: Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills. DESIGN: Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence). SETTING: The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center. RESULTS: Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction. CONCLUSION: This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.

Surgical Cholecystectomy Score (SCS) for grading the difficulty of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic gall stone disease. A good scoring system is necessary to standardize the reporting. Our aim was to develop and validate an objective scoring system, the Surgical Cholecystectomy Score (SCS) to grade the difficulty of LC. METHODS: The study was conducted in a single surgical unit at a tertiary care hospital in two phases from January 2017 to April 2021. Retrospective data was analysed and the difficulty of each procedure was graded according to the modified Nassar's scoring system. Significant preoperative and intraoperative data obtained was given a weightage score. In phase II, these scores were validated on a prospective cohort. Each procedure was classified either as easy, moderately difficult or difficult. STATISTICAL ANALYSIS: A univariate analysis was performed on the data followed by a multivariate regression analysis. Bidirectional stepwise selection was done to select the most significant variables. The Beta /Schneeweiss scoring system was used to generate a rounded risk score. RESULTS: Data of 800 patients was retrieved and graded. 10 intraoperative parameters were found to be significant. Each variable was assigned a rounded risk score. The final SCS range for intraoperative parameters was 0-15. The scoring system was validated on a cohort of 249 LC. In the final scoring, cut off SCS of > 8 was found to correlate with difficult procedures. Score of < 2 was equivalent to easy LC. A score between 2 and 8 indicated moderate difficulty. The area under ROC curve was 0.98 and 0.92 for the intraoperative score indicating that the score was an excellent measure of the difficulty level of LCs. CONCLUSION: The scoring system developed in this study has shown an excellent correlation with the difficulty of LC. It needs to be validated in different cohorts and across multiple centers further.

Surgical Treatment of Pseudoaneurysm of the Right Hepatic Artery Following Cholecystectomy: A Case Report.

Pseudoaneurysms of the right hepatic artery following cholecystectomy are caused by either vascular damage or erosion after a biliary leak. Symptoms often include haemobilia, melena, vomiting, jaundice, and hemodynamic failure due to aneurysm rupture. The ideal treatment is arterial embolization or, in rare cases, stenting. We present a case of pseudoaneurysm of the right hepatic artery post-laparoscopic cholecystectomy. The patient presented with abdominal pain, vomiting, and hemodynamic failure on postoperative day 45. Magnetic resonance imaging (MRI) showed a large hematoma and a pseudoaneurysm of the right hepatic artery. A laparotomy was performed, and a large hematoma was found and evacuated. After the pringle maneuver, the pseudoaneurysm was resected. The right hepatic artery was ligated with clips, and a sub-hepatic drain was placed. The non-availability of emergency embolization forced surgical closure of the right hepatic artery, which is still the first-line treatment for such cases. Injury of the right hepatic artery is a rare complication, often overlooked by surgeons, and requires early diagnosis. Surgical treatment is reserved for cases of embolization failure or hemodynamic instability.

The influence of obesity on the safety of laparoscopic cholecystectomy: a retrospective analysis.

Introduction: The increasing prevalence of obesity worldwide has raised concerns about its impact on surgical outcomes across various procedures. Laparoscopic cholecystectomy (LC), a common surgical intervention for benign gallbladder disease, is no exception. The relationship between obesity and LC outcomes remains complex and merits further investigation. Aim: This retrospective study aimed to assess the influence of obesity on the safety and surgical outcomes of LC. Material and methods: Patients were divided into 2 groups: those with obesity (body mass index (BMI) ≥ 30 kg/m²) and non-obese controls (BMI < 30 kg/m²). Baseline characteristics, operative duration, hospitalization length, and post-operative complications, categorized by the Clavien-Dindo classification, were evaluated. Results: Among 116 patients with obesity and 176 non-obese controls, differences in age and gender were noted but were not clinically significant. Operative time was longer in the group with obesity. Hospitalization length and adverse event occurrence did not differ significantly. Importantly, post-operative complications showed no substantial differences between the groups, suggesting that obesity may not significantly increase the complication risk in this population. Conclusions: Obesity may not substantially elevate the risk of adverse events or severe complications following LC in this patient population. Careful patient selection, preoperative evaluation, and surgical technique remain crucial. Further research in larger, diverse populations is needed to validate these findings.

The effects of previous abdominal surgery and the utilisation of modified access techniques on the operative difficulty and outcomes of laparoscopic cholecystectomy and bile duct exploration.

BACKGROUND: Early reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them. METHOD: Prospectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis. RESULTS: Of 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3-5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications. CONCLUSION: The risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks.

Analysis of quality of life in patients after transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery.

BACKGROUND: At present, laparoscopic cholecystectomy (LC) is the main surgical treatment for gallstones. But, after gallbladder removal, there are many complications. Therefore, it is hoped to remove stones while preserving the function of the gallbladder, and with the development of endoscopic technology, natural orifice transluminal endoscopic surgery came into being. AIM: To compare the quality of life, perioperative indicators, adverse events after LC and transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery (EGPS) in patients with gallstones. METHODS: Patients who were admitted to The First Affiliated Hospital of Xinjiang Medical University from 2020 to 2022 were retrospectively collected. We adopted propensity score matching (1:1) to compare EGPS and LC patients. RESULTS: A total of 662 cases were collected, of which 589 cases underwent LC, and 73 cases underwent EGPS. Propensity score matching was performed, and 40 patients were included in each of the groups. In the EGPS group, except the gastrointestinal defecation (P = 0.603), the total score, physical well-being, mental well-being, and gastrointestinal digestion were statistically significant compared with the preoperative score after surgery (P < 0.05). In the LC group, except the mental well-being, the total score, physical well-being, gastrointestinal digestion, the gastrointestinal defecation was statistically significant compared with the preoperative score after surgery (P < 0.05). When comparing between groups, gastrointestinal defecation had significantly difference (P = 0.002) between the two groups, there was no statistically significant difference in the total postoperative score and the other three subscales. In the surgery duration, hospital stay and cost, LC group were lower than EGPS group. The recurrence factors of gallstones after EGPS were analyzed: and recurrence was not correlated with gender, age, body mass index, number of stones, and preoperative score. CONCLUSION: Whether EGPS or LC, it can improve the patient's symptoms, and the EGPS has less impact on the patient's defecation. It needed to, prospective, multicenter, long-term follow-up, large-sample related studies to prove.

A Systematic Review and Meta-Analysis of the Management of Gallstone Cholecystitis and Common Biliary Duct Stones to Reduce the Incidence of Complications in Elderly Patients.

As the age increases particularly above the age of 50 years, there is a significantly higher risk of developing gallstone-related complications especially cholecystitis and common bile duct stones with its associated consequences. Complications that arise after surgical operations for cholecystitis have been reported to have negative impacts on senior patients. These effects include a higher rate of complications, a longer hospital stay, higher expenditures, and decreased patient satisfaction. Therefore, finding the most effective treatment for cholecystitis in older patients is still a challenge. The aim of the study was carried out in order to identify many approaches that can be taken in the treatment of cholecystitis and stones in the common bile duct in older patients. A search was conducted through Medline (PubMed), EMBASE, ProQuest, and Cochrane using relevant Medical Subject Heading (MeSH) terms and keywords (elderly, age over 50, cholecystitis, bile duct stones, cholecystectomy, ERCP, surgical, conservative management, and open). The searches were limited to studies on elderly individuals over 50 who had cholecystectomy and endoscopic retrograde cholangiopancreatography between January 2000 and December 2022. The meta-analysis used the Mantel-Haenszel odds ratio (MHOR) and 95% confidence interval (CI). Aries Systems Corporation's Editorial Manager® (Aries Systems Corporation, North Andover, USA) and ProduXion Manager® (Aries Systems Corporation, North Andover, USA) facilitated the study. Out of 102 citations, 39 studies were selected for further study. After that, 18 studies were eliminated, leaving 21 for meta-analysis. The study found a protective risk of cholecystitis in cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). Developing cholecystitis was substantially lower in early cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). There was no significant difference in cholecystitis risk between open and laparoscopic surgery (MHOR = 0.65; 95%, CI = 0.41 to 1.04; p 0.07). Cholecystectomy performed at an earlier stage protects elderly patients from developing recurrent cholecystitis. In contrast to late cholecystitis, in which the patient would experience several attacks of cholecystitis, early cholecystectomy protects against the recurrence of the condition.

The Effect of Pneumoperitoneum on the Ankle-brachial Index of the Patients Undergoing Laparoscopic Cholecystectomy: An Observational Study.

Background: Improvement in the perioperative care has led to increased use of minimally invasive surgeries. Multiple physiological changes during minimally invasive surgeries are attributed to the creation of pneumoperitoneum. Materials and Methods: One hundred and nine patients who underwent laparoscopic cholecystectomy at a tertiary care hospital in north India meeting the inclusion and exclusion criteria were enrolled. Results: Out of the total 109 patients, 13 were males and 96 females (M:F = 1:7.3), the mean basal metabolic rate was 28.95 kg/m2. The mean systolic and diastolic blood pressure of the upper limb were 134.33 + 17.545 and 80.69 + 11.59 respectively. The mean systolic and diastolic blood pressure in lower limb (LL) were 142.32 + 21.552 and 79.44 + 11.94, respectively. Significant rise in the SBP was noticed in LL at the time of creation of Pneumoperitoneum and after changing the position for surgery (P < 0.05). The diastolic pressure in the LL rises significantly in the LL after creation of pneumoperitoneum, at induction, after reverse Trendelenburg position and extubation (P < 0.05). The mean arterial pressure increased significantly in the LL after the creation of pneumoperitoneum and persisted till the extubation (P < 0.05). A significant rise of ankle-brachial index (ABI) was observed in the patients after the creation of pneumoperitoneum and it remained significant till 15 min into surgery (P < 0.05). There was no correlation of ABI with weight and age of the patients on Pearson correlation. Conclusion: There is rise in ABI of the patients undergoing laparoscopic cholecystectomy at the time of creation of pneumoperitoneum, after Trendelenburg position and 15 min into surgery.

Acute Cholecystitis in a Patient With Situs Inversus.

A rare disorder called situs inversus partialis (SIP) is characterized by the transposition of organs in the abdomen or thoracic cavity from one side of the body to the other (the mirror image of normal). Autosomal dominant, autosomal recessive, rare genetic mutations, and X-linked recessive inheritance patterns have been identified to be involved in this condition. Laparoscopic cholecystectomies have been successfully performed on patients with SIT. Due to challenges in spatial orientation and the identification of anatomical variations brought on by the abdominal organs' mirror image, surgery is more complicated and takes longer. We describe a 40-year-old female case who had acute cholecystitis. Laparoscopic cholecystectomy was used to treat this patient, a highly effective procedure for both the treatment and care of these patients. Post-surgical examination and follow-up revealed improvement in the patient's condition without subsequent complications.

Reversing the Norm: Successful Cholecystectomy in a Patient With Situs Inversus.

Situs inversus totalis (SIT), affecting 1 in 6,000 to 10,000 individuals, involves a complete reversal of chest and abdominal organs. About one-third of SIT cases coincide with primary ciliary dyskinesia, leading to diverse symptoms. Surgical challenges arise in procedures like liver transplantation and biliary interventions due to organ abnormalities. This case study explores cholecystitis in a patient with SIT, offering insights crucial for navigating complexities in treating this congenital anomaly. A 34-year-old Arab female, who was a known SIT case, came to the hospital complaining of abdominal pain in the left upper quadrant. After conducting a chest X-ray and an abdominal ultrasound, the patient was diagnosed with cholecystitis. She then underwent a planned cholecystectomy to remove her gallbladder. SIT presents challenges when it comes to procedures such as laparoscopic cholecystectomy (LC). Nevertheless, the proficiency of skilled surgeons, meticulous preoperative planning, and strict adherence to surgical principles render the execution of LC on patients with SIT both achievable and secure. The successful completion of over 120 cases serves as evidence of the adaptability and precision that can be achieved through surgery for individuals with SIT.

Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis.

Laparoscopic cholecystectomy (LC) is the established gold standard treatment for benign gallbladder diseases. However, robotic cholecystectomy is still controversial. Therefore, we aimed to compare intraoperative and postoperative outcomes in LC and robotic-assisted cholecystectomy (RAC) in patients with nonmalignant gallbladder conditions. PubMed, Scopus, Cochrane Library, and Web of Science were systematically searched for studies comparing RAC to LC in patients with benign gallbladder disease. Only randomized trials and non-randomized studies with propensity score matching were included. Mean differences (MDs) were computed for continuous outcomes and odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.2.3. A total of 13 studies comprising 22,440 patients were included, of whom 10,758 patients (47.94%) underwent RAC. The mean age was 48.5 years and 65.2% were female. Compared with LC, RAC significantly increased operative time (MD 12.59 min; 95% CI 5.62-19.55; p < 0.01; I2 = 79%). However, there were no significant differences between the groups in hospitalization time (MD -0.18 days; 95% CI - 0.43-0.07; p = 0.07; I2 = 89%), occurrence of intraoperative complications (OR 0.66; 95% CI 0.38-1.15; p = 0.14; I2 = 35%) and bile duct injury (OR 0.99; 95% CI 0.64, 1.55; p = 0.97; I2 = 0%). RAC was associated with an increase in operative time compared with LC without increasing hospitalization time or the incidence of intraoperative complications. These findings suggest that RAC is a safe approach to benign gallbladder disease.

Comparative Study of Levels of Serum Bilirubin, Serum Transaminase, Serum Alkaline Phosphatase, and Prothrombin Time After Laparoscopic Cholecystectomy and Open Cholecystectomy.

Laparoscopic cholecystectomy (LC) is universally accepted as the gold standard treatment for symptomatic gallstones. However, it has some drawbacks. Some of the major drawbacks of LC include increased bile duct injuries and longer operation time. Furthermore, it may cause changes in the body systems, such as alterations in acid-base, pulmonary status, cardiovascular system, and liver function. Thus far, no causes for these changes have been identified. This study aimed to evaluate the effect of laparoscopic and open cholecystectomy on liver enzymes, prothrombin time (PT), and serum bilirubin. In the current study, we found significant increases in aspartate transferase (AST), alanine transaminase (ALT), and total bilirubin, on day 1 and day 3 after LC but no significant change in alkaline phosphatase (ALKP) and PT. It is important for surgeons to know about these transient changes in the immediate postoperative period to avoid misdiagnosis and adopt proper treatment and management.

Avoidance of bile duct injury in laparoscopic cholecystectomy with feasible intraoperative resources: A cohort study.

Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries and is considered the standard treatment for cholelithiasis. However, it is associated with a risk of bile duct or hepatic artery injuries. This study evaluated the safety of LCs and the conversion rate (CR) by achieving a critical view of safety (CVS) and identification of Rouviere's sulcus (RS). This was a single-group cohort study that included consecutive patients undergoing LC at Smart Health Tower (Sulaimani, Iraq) from January 2021 to January 2023. The data were prospectively collected from patients' profiles or surgical notes within the hospital's database. A total of 419 patients underwent LC, of which females were the predominant gender (78.5%). The mean and median ages of the cases were 46.3±15.8 and 45 years, with a range of 2-90 years, respectively. The most common indications for surgery were biliary colic (69.5%), followed by acute cholecystitis (23.9%). The duration of the operations was significantly shorter for cases in which the CVS (45.6±17.9 min) or identification of RS (45.6±18.6 min) was achieved compared to those where the CVS (63.7±27.7 min) or RS (50.7±21.7 min) was not observed. Surgeries for patients with both CVS achievement and RS identification were also significantly less time-consuming (44.3±17.6) than counterparts (53.3±22.6). Among the cases without CVS achievement or RS identification (n=97, 23%), eight (8.2%) had adhesions, 12 (12.4%) had a distended gallbladder (GB) and 10 (10.3%) had thick GB walls. In addition, four (4.1%) experienced GB perforation, two (2.1%) had bleeding and one (1%) had stone spillage. There was no conversion. The achievement of CVS and identification of RS are practical landmarks in performing safe LC and decreasing the CR.

Case report: Rare floating gallbladder torsion in a child.

Gallbladder Torsion (GT) refers to serious biliary emergencies caused by the torsion of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. It is very rare, especially in children. The clinical data of a child with floating gallbladder torsion who was treated in our hospital on March 14, 2024, were analyzed. A 6-year-old girl presented with abdominal pain and vomiting. Physical examination showed a mass in the right middle abdomen. Laboratory tests showed normal liver biochemical function and white blood cells. The benign lesion was considered by color Doppler ultrasound and CT, and the floating torsion of the gallbladder was diagnosed by MRCP and laparoscopic exploration. The child was treated with laparoscopic cholecystectomy (LC) and recovered well after the operation.

The Use of Neutrophil-to-Lymphocyte Ratio, Monocyte-to-Lymphocyte Ratio and Platelets-to-Lymphocyte Ratio in the Assessment of the Risk of Conversion and Complications After Cholecystectomy Performed Due to Symptomatic Cholelithiasis.

Purpose: Laparoscopic cholecystectomy is quite a safe procedure, as only about 2% of cases result in clinically significant postoperative complications. The occurrence of conversion and postoperative complications is associated with prolonged hospitalization and higher perioperative mortality. Some parameters assessed in preoperative laboratory tests are used to predict the risk of conversion and clinically significant postoperative complications. The aim of this study was to evaluate the usefulness of preoperative neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) and platelets-to-lymphocyte ratio (PLR) values in predicting the risk of conversion and complications in laparoscopic cholecystectomy performed due to symptomatic cholelithiasis. Patients and Methods: A retrospective analysis of patients operated on for symptomatic cholelithiasis was performed. The Results of preoperative laboratory tests were assessed - NLR, MLR and PLR. Their impact on early outcomes of surgical treatment was analyzed in the study population. Results: The analysis concerned 227 patients operated on for symptomatic cholelithiasis. The study group included 61 (26.9%) men and 166 (73.1%) women. As the NLR, MLR and PLR values increase, the length of hospitalization increases (rS 0.226, 0.247 and 0.181, respectively), as well as the risk of converting the procedure to an open method (p<0.05). Moreover, with increasing NLR and MLR values, the grade of postoperative complications according to the Clavien-Dindo scale increases (p 0.0001 and 0.008, respectively). The grade of postoperative complications does not depend on the PLR value. Conclusion: The risk of conversion can be assessed based on preoperative NLR, MLR and PLR values in patients undergoing surgery for symptomatic cholelithiasis. Elevated preoperative NLR and MLR values are associated with a higher grade of postoperative complications in the Clavien-Dindo scale.

Blunt dissection method using HiQ+ soft coagulation system for laparoscopic cholecystectomy in acute cholecystitis.

INTRODUCTION: During laparoscopic cholecystectomy for acute cholecystitis, it is often difficult to keep the surgical view dry because of inflammation-related tissue fragility and susceptibility to bleeding. The resulting inadequate surgical view can lead to bile duct or vascular injury. Soft coagulation systems are used to achieve hemostasis during various surgeries; however, the usefulness of soft coagulation during laparoscopic cholecystectomy for acute cholecystitis is unclear. We here demonstrate the usefulness and feasibility of blunt dissection and soft coagulation during this procedure. MATERIALS AND SURGICAL TECHNIQUE: We used blunt dissection and soft coagulation when performing laparoscopic cholecystectomy on two patients with acute cholecystitis. As with conventional laparoscopic cholecystectomy, four ports were inserted. After cutting the serosa by electrocautery, blunt dissection using soft coagulation was performed, exposing the inner subserosa. Maintaining this layer using blunt dissection with soft coagulation achieved a sufficiently clear view for safety. After resecting the cystic artery and duct, the gallbladder bed was also dissected by blunt dissection with soft coagulation. Blood loss was <20 mL in both patients. DISCUSSION: Blunt dissection with soft coagulation may be a useful and feasible means of keeping the surgical view dry and minimizing blood loss during laparoscopic cholecystectomy for acute cholecystitis.

Early laparoscopic cholecystectomy in severely comorbid patients with acute cholecystitis: results of a monocentric study.

Aim: The aim is to evaluate laparoscopic cholecystectomy safety based on American Society of Anesthesiologists score for acute cholecystitis in patients with comorbidities. Patients & methods: This is retrospective study of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2003 and 2021. According to their respective ASA-score, patients were divided into group 1: ASA1-2 and group 2: ASA3-4. Results: We collected 578 patients. Even though the gangrenous forms were more frequent and the operative time was longer in group 2, laparoscopic cholecystectomy seems safe and effective. We didn't observe any differences in terms of intraoperative incidents, open conversion rate, or postoperative complications compared with other patients. Conclusion: ASA3-4 patients with acute cholecystitis don't face elevated risks of complications or mortality during laparoscopic cholecystectomy.

This study, involving 578 patients with acute cholecystitis, assessed the safety of early laparoscopic cholecystectomy based on their health scores. Despite longer operative times and more gangrenous forms in higher-scored patients, laparoscopic cholecystectomy was found to be safe and effective. No significant differences in complications or mortality were observed compared with lower-scored patients. In conclusion, early laparoscopic cholecystectomy is considered a safe option for patients with higher health scores facing acute cholecystitis.

Study assessed laparoscopic cholecystectomy safety in high-risk patients with acute cholecystitis based on ASA scores. Despite longer operative times, it's a safe and effective option. #CholecystectomySafety.

Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review.

Artificial Intelligence (AI) is playing an increasing role in several fields of medicine. AI is also used during laparoscopic cholecystectomy (LC) surgeries. In the literature, there is no review that groups together the various fields of application of AI applied to LC. The aim of this review is to describe the use of AI in these contexts. We performed a narrative literature review by searching PubMed, Web of Science, Scopus and Embase for all studies on AI applied to LC, published from January 01, 2010, to December 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly improve surgical efficiency and accuracy during LC. Future prospects include speeding up, implementing, and improving the automaticity with which AI recognizes, differentiates and classifies the phases of the surgical intervention and the anatomic structures that are safe and those at risk.