Laparoscopic cholecystectomy after gallbladder preservation: TG18 Delphi score quantifies surgical difficulty.

Aims: To determine if early laparoscopic cholecystectomy (LC) for acute cholecystitis, performed in accordance with the Tokyo Guidelines for the Management of Acute Cholangitis and Cholecystitis, was more effective than delayed LC. Methodology: We compared surgical difficulties, clinical courses and complications between 32 patients undergoing delayed LC and 30 undergoing early LC. Results: Delayed LC was associated with more surgical difficulties than early LC, including severe adhesion of the greater omentum (15/32 vs. 1/30), severe cicatrization of Calot’s triangle (15/32 vs. 3/30), inability to identify or skeletonize the cystic duct (18/32 vs. 3/30), and severe cicatrization of the gallbladder bed (27/32 vs. 1/30). Delayed LC was also associated with longer operating times (163 vs. 93 minutes), more conversions to open surgery (7/32 vs. 0/30), more complications (3/32 vs. 1/30), and longer hospitalization (30.5 vs. 10.2 days). Most early LCs was performed during overtime. Conclusions: Despite the retrospective nature of this study, the results demonstrated that changing treatment for acute cholecystitis from delayed to early LC, in accordance with the Tokyo Guidelines, could effectively reduce operation time, duration of symptoms and hospital stay, and thus be of significant benefit to patients. Further, prospective studies are needed to confirm these findings.

Introduction Laparoscopic cholecystectomy (LC) is a standard surgical procedure that general surgeons perform to treat acute cholecystitis. The presentation of this condition can vary in severity due to preoperative and intraoperative risk factors. Intraoperative scales such as the Parkland Grading Scale (PGS), Nassar Scale (NS), and G10 Score (G10S) evaluate these aspects. These scales help determine the severity of the condition, the need for conversion to open surgery, and the possibility of injury. However, their utility may differ between elective and emergency surgeries. Methods The objective of this study was to describe the clinical differences and intraoperative scalesas well as the conversion rate to open surgery and the incidence of bile duct injury (BDI) in patients who underwent LC postoperatively at the Hospital Regional General Ignacio Zaragoza(HRGIZ) in Mexico City. An observational, descriptive,retrospective cross-sectional study was conducted. Patients over 18 years treated in the General Surgery Service of HRGIZ for LC between March 2022 and April 2023 were included. Pregnant patients and those undergoing other surgeries were excluded. The analyzed variables included age, gender, type of procedure, surgical time, scales (PGS, NS, G10S), conversion rate to open surgery, and BDI. Descriptive and inferential statistics were used for data analysis, including chi-square tests, Student's t-tests, and differences in proportions, utilizing VassarStats 2023 (Vassar College, Poughkeepsie, US) and Microsoft Excel v2401 (Microsoft Corp., Redmond, US). Results A total of 445 postoperative LC patients were identified. Based on the inclusion criteria, a sample of 364 patients was analyzed and classified into two groups: scheduled procedures (139, 38.2%) and emergency procedures (225, 61.8%). Both groups showed a female prevalence, with an average age of 55±16 years for scheduled procedures and 49±15 years for emergencies (p<0.05). No significant differences were found in surgical time, bleeding volume, or hospital stay between the groups. A higher number of LCs were performed as emergencies (205, 56.3%) compared to scheduled procedures (129, 35.4%) (p<0.0002). Of the total procedures, 4.3% required conversion to open surgery, and three patients (0.82%) presented with BDI. Regarding the evaluated scales, the PGS showed results of 2.51±1.42 in scheduled procedures compared to 3.49±1.34 in emergencies, the G10S score was 2.71±1.76 in scheduled procedures and 4.38±1.93 in emergencies, and the NS showed 1.91±0.92 in scheduled procedures and 3.02±0.90 in emergencies (p<0.05 for all). A higher percentage of BDI and a higher conversion rate to open surgery were noted in emergency procedures rather than scheduled procedures (3.02 vs. 1.37). Conclusions This study highlights the critical role of intraoperative scoring systems in predicting surgical difficulty and associated risks in LC. The significant differences in scores between elective and emergency surgeries reinforce their value in guiding surgical decision-making and tailoring approaches to individual patients. By integrating these scales into routine practice, surgeons can enhance outcomes, particularly in high-risk cases, while reducing complications such as BDI. Future research should focus on multi-institutional validation to further establish their utility in diverse clinical settings.

BackgroundThe surgical difficulty of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) and the risk of bile duct injury (BDI) depend on the degree of fibrosis and scarring caused by inflammation; therefore, understanding these intraoperative findings is crucial to preventing BDI. Scarring makes it particularly difficult to perform safely and increases the BDI risk. This study aimed to develop an artificial intelligence (AI) system to indicate intraoperative findings of scarring in LC for AC.Materials and methodsAn AI system was developed to detect scarred areas using an algorithm for semantic segmentation based on deep learning. The training dataset consisted of 2025 images extracted from LC videos of 21 cases with AC. External evaluation committees (EEC) evaluated the AI system on 20 cases of untrained data from other centers. EECs evaluated the accuracy in identifying the scarred area and the usefulness of the AI system, which were assessed based on annotation and a 5-point Likert-scale questionnaire.ResultsThe average DICE coefficient for scarred areas between AI detection and EEC annotation was 0.612. The EEC’s average detection accuracy on the Likert scale was 3.98 ± 0.76. AI systems were rated as relatively useful for both clinical and educational applications.ConclusionWe developed an AI system to detect scarred areas in LC for AC. Since scarring increases the surgical difficulty, this AI system has the potential to reduce BDI.

Laparoscopic cholecystectomy (LC) is the preferred surgical approach for treating gallstone disease; however, there are cases that pose significant challenges, often leading to a switch to open surgery.This study aims to identify preoperative indicators that suggest a difficult laparoscopic cholecystectomy (LC), focusing on demographic factors, inflammatory markers, and intraoperative challenges.A prospective study was performed on patients diagnosed with acute or chronic cholecystitis, examining factors such as gender, age, diabetes mellitu), CRP, ESR, and TC.The findings revealed a strong association between male gender, older age, and diabetes mellitus with surgical complications (p = 0.001).CRP, ESR, and TLC were significantly linked to intraoperative challenges and the need for conversion to open surgery.The severity grade of the Tokyo Guidelines (TG-13) was substantially associated with surgical difficulty (p = 0.001).These findings points out the significance of preoperative evaluation in recognising high-risk patients, facilitating enhanced surgical planning and improved patient outcomes.Nevertheless, constraints such as a single-center design and retrospective data collecting require more multi-center prospective research to improve predictive accuracy and investigate sophisticated imaging and biochemical indicators for enhanced risk stratification.

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

PurposeThe Tokyo Guidelines 2018 introduced the Surgical Difficulty Score (TGDS18) to assess laparoscopic cholecystectomy (LC) difficulty based on intraoperative findings. This study aimed to predict surgical difficulty preoperatively using clinical factors correlated with TGDS18.MethodsOf 369 LC cases for cholecystitis (Jan 2014–Jul 2024), 106 with operative video data were analyzed. Multivariate analysis of 69 with preoperative CT (≤14 days) evaluated the association between preoperative clinical findings and TGDS18 sub‐scores (around the gallbladder, Calot's triangle, gallbladder bed, additional findings, unrelated to inflammation).ResultsTGDS18 was positively correlated with operative time, blood loss, and hospital stay (all p < .001). Patients undergoing subtotal cholecystectomy had higher TGDS18 scores (median 20, p < .001). Six preoperative findings strongly associated with TGDS18 sub‐scores were identified: calcified stone in cystic duct, TG18 Grade ≥2, preoperative gallbladder drainage, urgent operation, pericholecystic inflammation, and age‐adjusted Charlson comorbidity index ≥7. The rate of subtotal cholecystectomy increased with the number of findings linked to the “Calot's triangle” sub‐score—cystic duct stone and TG18 Grade ≥2. (0% with no findings, 8% with one finding, and 23% with both, p = .009). Similarly, the risk of cholecystectomy requiring the posterior wall left can be predicted by the number of clinical findings related to the ‘Gallbladder bed’ sub‐score (p = .009).ConclusionsThe clinical findings linked to TGDS18 allow tailored preoperative strategies for acute cholecystitis.

Combining preoperative C-reactive protein values with the Tokyo Guidelines 2018 grading criteria can enhance the prediction of surgical difficulty in early laparoscopic cholecystectomy for acute cholecystitis

Objective To explore the methods and values of preoperative prediction of degree of difficulty in laparoscopic cholecystectomy.Methods The data on 56 patients undergoing laparoscopic cholecystectomy were retrospectively analyzed.All the patients received ultrasonography preoperatively.The criteria for degree of difficulty of the procedure were determined.According to the criteria,the patients were divided into easy procedure group ( 16 patients ) and difficult procedure group ( 40 patients ).The predicted results were compared with the actual results.Results The procedure was successfully performed on 52 of the 56 patients,and the rest 4 had to undergo laparotomy.The procedure was determined as difficulty in 40 patients intraoperatively,which had no significant differences with preoperative prediction ( P ＞ 0.05 ).Age,body mass index,history of abdominal surgery,and amount of onset were related to degree of surgical difficulty ( P＜ 0.05 ).Gallbladder wall thickening,stone stuck in the gallbladder neck,and gallbladder with stones type were the major factors for the difficulty in the procedure.Conclusions Ultrasonic examination has a predictive value of degree of difficulty in laparoscopic cholecystectomy but should combine with age,body mass index,history of abdominal surgery,amount of onset,and length of disease course. Key words: Laparoscopy; Cholecystectomy; Preoperative difficulty; Prediction; Ultrasound

Cholelithiasis is increasing in the pediatric population, and there are currently no guidelines for the management of asymptomatic patients with both cholelithiasis and a predisposing condition. This study seeks to highlight situations where prophylactic cholecystectomy may be desirable. We retrospectively reviewed the medical records of children who underwent elective laparoscopic cholecystectomy between October 2011 and September 2022. Thirty-two patients were included in the study. Five different groups of patients were identified based on associated pathologies. Twenty-six patients were symptomatic (81.25%), and six were asymptomatic (18.75%). All patients underwent a laparoscopic cholecystectomy. Hematologic and cystic fibrosis patients with asymptomatic cholelithiasis had a shorter length of hospital stay than patients with the same condition who progressed from asymptomatic to symptomatic gallstone disease. Consequently, patients with associated diseases (particularly hematologic diseases and cystic fibrosis) may benefit from early laparoscopic cholecystectomy, which could reduce the probability of surgical difficulties and shorten the length of hospital stay.

Grading scales for the surgical difficulty of laparoscopic cholecystectomy (LC) had been mentioned but not common. In order to clarify and compare grading score for the surgical difficulty of LC, we conducted this study to present our grading scoring method by measuring the time of laparoscopic cholecystectomy.

Preoperative evaluation to predict technical difficulties of laparoscopic cholecystectomy on the basis of histological inflammation findings on resected gallbladder

Background: With the establishment of laparoscopic cholecystectomy as gold standard management of cholelithiasis, the current stress is being given on increasing patient safety and reducing the post-operative morbidity associated with this procedure. An emerging trend is to use of low-pressure pneumoperitoneum in an attempt to lower the impact of pneumoperitoneum while providing adequate working space.Methods: In this prospective randomized study 66 participants were allocated into two arms i.e. low-pressure pneumoperitoneum (LPP) and standard pressure pneumoperitoneum (SPP). The necessary data were collected using laboratory investigations, clinical examination and perioperative findings. Data were analyzed using suitable statistical software.Results: Mean duration of surgery, surgical difficulty and field visualization difficulty were insignificantly greaterin LPP group than SPP group. CO2 consumption was significantly less in LPP. Incidence of bile spillage, usage of drain was insignificantly increased in LPP. Post-operative pain was significantly greater in SPP group. Time for per oral tolerance of food and incidence of nausea were significantly greater in SPP group. Standard pressure group needed significantly more tramadol injection than LPP. There were no significant haemodynamic changes in SPP group compared to LPP group. Length of hospital stay was significantly greater in SPP.Conclusions: Laparoscopic cholecystectomy in low pressure pneumoperitoneum is safe and feasible. Intra-operative complications like operative field visualization, operative difficulties, conversion rates, duration of surgery are not affected moreover, low-pressure pneumoperitoneum, decreases consumption of intra-operative CO2, post-operative pain, shoulder tip pain, need of analgesia, nausea and promotes early per oral feeding, thus reduces hospital stay.

How do magnetic resonance cholangiopancreatography findings predict conversion from laparoscopic cholecystectomy for acute cholecystitis to bailout procedures?

Evidence from other professions suggests that training in teamwork and general cognitive abilities, collectively described as non-technical skills, may reduce accidents and errors. The relationship between non-technical teamwork skills and technical errors was studied using a behavioural marker system validated in aviation and adapted for use in surgery. 26 elective laparoscopic cholecystectomies were observed. Simultaneous assessments were made of surgical technical errors, by observation clinical human reliability assessment (OCHRA) task analysis, and non-technical performance, using the surgical NOTECHS behavioural marker system. NOTECHS assesses four categories: (1) leadership and management, (2) teamwork cooperation, (3) problem-solving and decision-making, (4) situation awareness. Each subteam (nurses, surgeons and anaesthetists) was scored separately on each of the four dimensions. Two observers - one surgical trainee and one human factors expert - were used to assess intra-rater reliability. The mean NOTECHS team score was 35.5 (95% C.I. +/- 1.88). The mean subteam scores for surgeons, anaesthetists and nurses were 13.3 (95% C.I. +/- 0.64), 11.4 (95% C.I. +/- 1.05), and 10.8 (95% C.I. +/- 0.87), respectively, with a significant difference between surgeons and anaesthetists (U = 197, p = 0.009), and surgeons and nurses (U = 0.134, p <or= 0.001). Inter-rater reliability was found to be strong (alpha = 0.88). There were between zero and six technical errors per operation, with a mean of 2.62 (95% C.I. +/- 0.55), which were negatively correlated with the surgeons situational awareness scores (rho = -0.718, p < 0.001). Non-technical skills are an important component of surgical skill, particularly in relation to the development and maintenance of a surgeon's situational awareness. Experience from other industries suggests that it may be possible to improve the ability of surgeons to manage their own situation awareness, through training, intraoperative briefings and intraoperative workload management. In the future, it may be possible to use non-technical performance as a surrogate measure for technical performance, either for early identification of surgical difficulties, or as a method of evaluation by which non-surgically trained observers.

Use of 10-Point Operative Scoring System (G10 Score) in Predicting Conversion of Laparoscopic Cholecystectomy to Open