Intraoperative cholangiography facilitates simple transcystic clearance of ductal stones in units without expertise for laparoscopic bile duct surgery.

BACKGROUND: In the absence of facilities and expertise for laparoscopic bile duct exploration (LBDE), most patients with suspected ductal calculi undergo preoperative endoscopic duct clearance. Intraoperative cholangiography (IOC) is not performed at the subsequent laparoscopic cholecystectomy. This study aimed to investigate the rate of successful duct clearance after simple transcystic manipulations. METHODS: This prospective study investigated 1,408 patients over 13 years in a unit practicing single-session management of biliary calculi. For the great majority, IOC was attempted. Abnormalities were dealt with by flushing of the duct, glucagon injection, Dormia basket trawling, choledochoscopic transcystic exploration, or choledochotomy. RESULTS: Of 1,056 cholangiograms performed (75%), 287 were abnormal (27.2%). Surgical trainees, operating under supervision, successfully performed 24% of all cholangiograms. Of 396 patients admitted with biliary emergencies, 94.1% had abnormal cholangiograms. Of the 287 patients with abnormal IOCs, 9.4% required no intervention, 18% were clear after glucagon and flushing, and 13% were cleared using Dormia basket trawling under fluoroscopy. A total of 95 patients required formal LBDE, and 2 required postoperative endoscopic retrograde cholangiopancreatography (ERCP). No postoperative ERCP for retained stones was required after simple transcystic manipulation. Eight conversions occurred, one during a transcystic exploration. Follow-up evaluation continued for as long as 6 years in some cases. Two patients had recurrent stones after LBDE and a clear postoperative tube cholangiogram. CONCLUSION: In this series, 10% of the abnormal cholangiograms occurred in patients without preoperative risk factors for bile duct stones. Altogether, 88 IOCs (31%) were cleared after either simple flushing or trawling with a Dormia basket. Formal LBDE was not required for 40% of abnormal cholangiograms. Simple transcystic manipulations to clear the bile ducts justify the use of routine IOC in units without laparoscopic biliary expertise.

Voice recognition interfaces (VRI) optimize the utilization of theatre staff and time during laparoscopic cholecystectomy.

During laparoscopy, members of staff spend time setting up and de-activating the light source, camera and insufflator. Voice Recognition Interface (VRI) devices, such as HERMES (Stryker Europe, Montreux, Switzerland), enable the surgeon to perform and control these and other functions. They recognize the surgeon's voice and adjust the instruments in response to programmed verbal commands. The aim of this study was to evaluate HERMES with regards to the utilization of time and theatre staff during laparoscopic cholecystectomy. A total of 100 patients were randomized to either HERMES-assisted or standard laparoscopic cholecystectomy. Three time variables were measured for performing three VRI tasks: (1) The initial setting up of the light source and camera, (2) the activation of the insufflator, and (3) the deactivation of the insufflator and light source at the end of the operation. The mean (and standard deviation) of the time in seconds required for setting up the light source and camera was 27.6 (26.9) in non-HERMES operations and 11.7 (4.7) in HERMES-assisted cases (p<0.001). Insufflation time was 19.8 (13.3) vs. 6.7 (2.5) (p<0.001), and switch-off time was 19.5 (11.8) vs. 11.8 (5.7) (p<0.001). HERMES optimized the operating time and the utilization of theatre staff during laparoscopic cholecystectomy.