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Background: There are few reported outcomes of treatment of acute cholecystitis incorporating current guidelines for gallbladder dissection techniques and use of percutaneous tube cholecystostomy (PCT). The authors hypothesize PCT allows regression of peritoneal inflammation, but infundibular inflammation is increased at interval cholecystectomy, resulting in greater requirement for advanced dissection techniques. Methods: Between December 2009 and July 2023, 1222 patients were admitted with acute cholecystitis and ultimately underwent cholecystectomy. Of these 1222 patients, there were 876 patients that underwent urgent (within 10 days) cholecystectomy (UrgSurg), 170 patients underwent interval cholecystectomy (10 or more days) after antibiotic therapy (IntMed), and 175 patients that underwent PCT and interval cholecystectomy (IntTube). Minimally invasive operation was attempted in all patients. Patient demographics, comorbidities, surgical techniques (Critical View of Safety (CVS), infundibulum down, fundus-down, subtotal fenestrating, subtotal reconstituting, and conversion to open operation), and surgical outcomes were reviewed retrospectively. Multivariate logistic regression was performed to identify if interval cholecystectomy was independently associated with more advanced dissection techniques or reinterventions. Results: Compared to the UrgSurg and IntMed patients, IntTube patients were significantly older (Median: 60 vs 66 vs 68, P < 0.001) and more often male (41.7% vs 47.6% vs 72.2%, P < 0.001). Additionally, IntTube patients were more likely to have medical comorbidities. Establishment of CVS was significantly less frequent in IntTube patients (61%) compared to UrgSurg patients (86%) and IntMed patients (85.9%) in unadjusted analysis (OR 0.26, P < 0.001) and in multivariable analysis after adjusting for potential confounders (OR 0.31, P < 0.001). There was no incidence of biliary injury, and no difference in rates of biliary reintervention among groups. Conclusion: Interval Cholecystectomy after PCT is independently associated with a lower rate of achieving CVS, and higher rate of requirement for advanced cholecystectomy dissection techniques. We report a low rate of complications using current guidelines for minimally invasive surgery for both urgent and interval cholecystectomy for acute cholecystitis. [ABSTRACT FROM AUTHOR]

Background: The protective impact of the Critical View of Safety (CVS) approach on the vasculo-biliary injuries during laparoscopic cholecystectomy (LC) depends largely upon the understanding of the normal and variant anatomy. Structures exposed during the acquisition of the CVS can deviate from the typical dual configuration of the cystic duct and artery (gallbladder pedicle) representing either a third (supernumerary) or atypical in course (heterotopic) element. The aim of this study was to determine the identity and the frequency of these anatomical elements and to propose anatomic schemata that can guide the achievement of CVS by surgeons. Method: Fourteen anatomic elements that can be encountered during LC were defined by members of the Hellenic task force on the typology of safe cholecystectomy using a literature review and expert consensus. Videos of 279 LCs performed for biliary colic were reviewed noting the presence of a third and or heterotopic anatomic element. In 108 LCs these elements were sought also intraoperatively. A CVS score according to Sanford and Strasberg was assigned to each video. Results: The normal configuration of the gallbladder pedicle was present in 233 cases (83.51%). A third element was detected in 42 cases (15.05%) and was arterial in 41 cases and biliary in 1 case. A heterotopic course concerned exclusively the cystic artery in 24 cases (8.6%). Neither of these two variant patterns compromised achievement of the CVS during LC. CVS scores improved with the addition of intraoperative assessment. Conclusion: Typical and aberrant anatomy of LC was defined and anatomic schemata proposed to help the surgeon better understand aberrant anatomy and confidently and safely handle any encountered element that deviates from the normal configuration of the gallbladder pedicle during laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy for acute cholecystitis carries an increased risk of biliovascular injuries. Fluorescence cholangiography (FC) is a valuable diagnostic tool for identifying extrahepatic bile ducts (EHBD). The objective of this study was to evaluate the efficacy of FC in delineating EHBD anatomy, both before and after dissection, based on the critical view of safety (CVS) principles. Methods: Urgently admitted patients were prospectively stratified into two groups, depending on whether they had mild or moderate acute cholecystitis, in accordance with the 2018 Tokyo guidelines. All patients were scheduled for an early laparoscopic cholecystectomy using FC and were administered a fixed dose of indocyanine green (ICG) intravenously 12 h prior to the surgical procedure. Results: A total of 108 patients—75 patients with mild acute cholecystitis and 33 patients with moderate acute cholecystitis—were included. More than four CVS steps were performed in 101 patients (93.5%). Less than four CVS steps were performed only in seven patients—three (2.5%) patients with mild acute cholecystitis and four (4%) patients with moderate acute cholecystitis. The achievement of the CVS principles and the visualization rate using FC significantly increased in both patient groups, ranging from 3% before CVS to 100% after CVS (p < 0.001). In both groups, the cystic duct was visualized in most patients after CVS and FC, followed by the common bile duct and the common hepatic duct. Conversely, even after using CVS and FC, the visualization of the confluence of the cystic and common hepatic ducts remained less likely and challenging in both groups (57.3% in mild patients vs. 33.3% in moderate patients; p = 0.022). Background liver fluorescence disturbance was observed equally in both patient groups (6–11%), but it did not reach statistical significance. The median operative time was 60 ± 25 min in patients with mild acute cholecystitis compared to 85 ± 37 min in patients suffering from moderate acute cholecystitis (p < 0.001). No postoperative complications or biliovascular injuries were observed. Conclusions: FC is a convenient, safe, and efficacious procedure for attaining CVS principles and identifying the EHBD anatomy in most patients. The procedure showed superior results in mild acute cholecystitis patients in comparison to moderate acute cholecystitis patients. [ABSTRACT FROM AUTHOR]

Background: The gold standard treatment of acute cholecystitis is early laparoscopic cholecystectomy (LC), as indicated in the Tokyo Guidelines (TG). However, the definition of "early" is still unclear. In 2013, TG suggested surgical intervention within 72 h from the onset of the symptoms; however, according to the 2018 revision, LC must be performed as soon as possible, regardless of symptom onset. Therefore, the optimal timing for surgery is still debated. In order to avoid any complications, surgeons need to know all the surgical strategies for safety in case of a difficult cholecystectomy. Methods and Materials: Starting from January 2023 at Cittiglio Hospital (Italy), the following strategies were implemented: LC within 72 h from the onset of symptoms, systematic intraoperative use of indocyanine green fluorescence cholangiography, systematic identification of the Critical View of Safety (CVS), and subtotal cholecystectomy when the CVS was impossible to identify. We retrospectively analyzed a cohort of patients who underwent LC in our surgical department, subdividing them into two groups: Group 1 (G1) included patients operated on in 2022, and Group 2 (G2) included patients operated on in 2023. End points were length of stay and in-hospital postoperative complications, with particular interest in biliary duct injury. Results: Overall, 210 LC have been performed (97 in G1 and 113 in G2). After the introduction of the new safety strategy, the median length of stay (3 days in G1 vs. 2 in G2), BDI rate (2 in G1 vs. 0 in G2), and conversion rate to open procedure (5 in G1 vs. 1 in G2) were decreased. Conclusions: Our data are promising, highlighting that LC with the standardization of new safety strategies, especially in case of acute cholecystitis, immediately improves surgical outcomes in terms of length of stay and complications. [ABSTRACT FROM AUTHOR]

Background and objectives: Laparoscopic cholecystectomy (LC) is the most commonly performed operation in general surgery in the Western World. Gallbladder surgery, although most of the time simple, always offers the possibility of unpleasant surprises. Despite progress, the incidence of common bile duct injury is 0.2–0.4%, causing devastating implications for the patient and the surgeon. This is mainly due to the failure to identify the normal anatomy properly. The literature review reveals a lack of structured knowledge in the surgical anatomy of cholecystectomy. The aim of this study was to develop a framework with a common anatomical language for safe laparoscopic and open cholecystectomy. Materials and Methods: The Hellenic Task Force group on the typology for Safe Laparoscopic Cholecystectomy performed a critical review of the literature on the laparoscopic anatomy of cholecystectomy. The results were compared with those of a clinical study of 279 patients undergoing LC for uncomplicated symptomatic gallstone disease. Results: Fourteen elements encountered during LC under the critical view of safety (CVS) approach were determined. The typical vascular–biliary pedicle with one cystic duct distributed laterally (or caudally) and one cystic artery medially (or cranially) lying at any point of the hepatocystic space was found in 66% of the cases studied. Anatomical schemata were formulated corresponding to the norm and four variations. Conclusions: The proposed cognitive anatomical schemata summarize simply what one can expect in terms of deviation from the norm. We believe that the synergy between the correct application of the CVS and the structured knowledge of the surgical anatomy in cholecystectomy helps the surgeon to handle non-typical structures safely and to complete the laparoscopic or open cholecystectomy without vascular–biliary injuries. [ABSTRACT FROM AUTHOR]

Bile duct injury rates in laparoscopic cholecystectomy remain higher than during open cholecystectomy. Intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. Standard laparoscopic cholecystectomy requires proper dissection of Calot’s triangle to achieve the critical view of safety (CVS). The CVS is the end product of dissection, and bile duct injuries occur before the conclusion of that process. The CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. A complete strategy of safety should therefore include early recognition of difficulties and identification of cholecystectomies, when the CVS cannot be achieved, in order to utilize new intraoperative technologies to clarify the anatomy. Fixed anatomical landmarks can help in proper orientation to ascertain the surgical anatomy correctly during surgery. Encompassed within the review are insights into identifying critical landmarks for assessing the positioning of vital structures in compromised anatomical conditions.

Recent advances in artificial intelligence (AI) have sparked a surge in the application of computer vision (CV) in surgical video analysis. Surgical complications often occur due to lapses in judgment and decision-making. In laparoscopic cholecystectomy, achievement of the critical view of safety is commonly advocated to prevent bile duct injuries. However, bile duct injuries rates remain stable, probably due to inconsistent application or a poor understanding of critical view of safety. Advances in AI have made it possible to train algorithms that identify anatomy and interpret the surgical field. AI-based CV techniques may leverage surgical video data to develop real-time automated decision support tools and surgeon training systems. The effectiveness of CV application in surgical procedures is still under early evaluation. The review considers the commonly used deep learning algorithms in CV and describes their usage in detail in four application scenes, including phase recognition, anatomy detection, instrument detection and action recognition in laparoscopic cholecystectomy. The MedLine, Scopus, and IEEE Xplore databases were searched for publications up to 2024. The keywords used in the search were “laparoscopic cholecystectomy”, “artificial intelligence”. The currently described applications of CV in laparoscopic cholecystectomy are limited. Most current research focus on the identification of workflow and anatomical structure, while the identification of instruments and surgical actions is still awaiting further breakthroughs. Future research on the use of CV in laparoscopic cholecystectomy should focus on application in more scenarios, such as surgeon skill assessment and the development of more efficient models.

Laparoscopic cholecystectomy is associated with a higher incidence of biliary/vasculary injuries than open cholecystectomy. Anatomical misperception is the most common underlying mechanism of such injuries. The critical view of safety (CVS) has been shown to be a good way of getting secure anatomical identification. It is highly recommended by various guidelines. Conceptually, CVS is a method of target identification, with the targets being the two cystic structures. It entails three basic steps as follows: 1) complete clearance of fibrous and fatty tissue from the hepatocystic triangle, 2) separation of the lower part of the gallbladder from the cystic plate, so that 3) two and only two structures are seen entering the gallbladder. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. The critical view of safety can be achieved in most cases during laparoscopic cholecystectomy. However, its poor understanding and low adoption rates among practicing surgeons have been global problems. Increasing awareness about the critical view of safety can increase its use in routine surgical practice.

Objective: To examine the use of surgical intelligence for automatically monitoring critical view of safety (CVS) in laparoscopic cholecystectomy (LC) in a real-world quality initiative. Background: Surgical intelligence encompasses routine, artificial intelligence-based capture and analysis of surgical video, and connection of derived data with patient and outcomes data. These capabilities are applied to continuously assess and improve surgical quality and efficiency in real-world settings. Methods: Laparoscopic cholecystectomies conducted at 2 general surgery departments between December 2022 and August 2023 were routinely captured by a surgical intelligence platform, which identified and continuously presented CVS adoption, surgery duration, complexity, and negative events. In March 2023, the departments launched a quality initiative aiming for 75% CVS adoption. Results: Two hundred seventy-nine procedures were performed during the study. Adoption increased from39.2%in the 3 preintervention months to 69.2% in the final 3 months (P < 0.001). Monthly adoption rose from 33.3% to 75.7%. Visualization of the cystic duct and artery accounted for most of the improvement; the other 2 components had high adoption throughout. Procedures with full CVS were shorter (P = 0.007) and had fewer events (P = 0.011) than those without. OR time decreased following intervention (P = 0.033). Conclusions: Surgical intelligence facilitated a steady increase in CVS adoption, reaching the goal within 6 months. Low initial adoption stemmed from a single CVS component, and increased adoption was associated with improved OR efficiency. Real-world use of surgical intelligence can uncover new insights, modify surgeon behavior, and support best practices to improve surgical quality and efficiency. [ABSTRACT FROM AUTHOR]

Key Clinical Message: If patient anatomy or disease does not allow for a traditional or partial cholecystectomy, an omental pedicle plug may be a viable option to limit the risk of postoperative uncontrolled bile leak from the cystic duct and to control patient symptoms. [ABSTRACT FROM AUTHOR]

BACKGROUND: Current descriptions of the history of subtotal cholecystectomy require more details and accuracy. The first cholecystectomy was performed by Carl Langenbuch in the Lazarus hospital of Berlin on 15 July 1882. AIMS AND OBJECTIVE: To Study the outcome of Laparoscopic Subtotal cholecystectomy without Cystic Duct Ligation (Open tract or fenestrative) for difficult Cholecystitis. METHODS AND MATERIALS: A Prospective observational study was conducted in the department of General surgery, IQ City Medical College and Hospital, Durgapur with patients of 25 to 60 years of age, posted for laparoscopic cholecystectomy between January 2015 to December 2022, with per-operative finding of difficult anatomy, where critical view of safety was not achieved after 30 minutes of laparoscopic procedure. RESULT In our study, 36 (21.05%) patients with bile leak, 9 (5.26%) were prolonged beyond 2 weeks, out of which further 4 settled down soon on their own, but rest 5 with deranged LFT not. So, ERCP and CBD stenting was arranged for them, which settled down the bile leak in them. CONCLU SION: Opened tract or fenestrative laparoscopic subtotal cholecystectomy (LSTC without is a relatively cystic duct ligation) straightforward, easy, safe and effective alternative to open conversion when dissection of Calot's triangle is hazardous. [ABSTRACT FROM AUTHOR]

Background and objectives: Laparoscopic cholecystectomy (LC) is the most commonly performed operation in general surgery in the Western World. Gallbladder surgery, although most of the time simple, always offers the possibility of unpleasant surprises. Despite progress, the incidence of common bile duct injury is 0.2–0.4%, causing devastating implications for the patient and the surgeon. This is mainly due to the failure to identify the normal anatomy properly. The literature review reveals a lack of structured knowledge in the surgical anatomy of cholecystectomy. The aim of this study was to develop a framework with a common anatomical language for safe laparoscopic and open cholecystectomy. Materials and Methods: The Hellenic Task Force group on the typology for Safe Laparoscopic Cholecystectomy performed a critical review of the literature on the laparoscopic anatomy of cholecystectomy. The results were compared with those of a clinical study of 279 patients undergoing LC for uncomplicated symptomatic gallstone disease. Results: Fourteen elements encountered during LC under the critical view of safety (CVS) approach were determined. The typical vascular–biliary pedicle with one cystic duct distributed laterally (or caudally) and one cystic artery medially (or cranially) lying at any point of the hepatocystic space was found in 66% of the cases studied. Anatomical schemata were formulated corresponding to the norm and four variations. Conclusions: The proposed cognitive anatomical schemata summarize simply what one can expect in terms of deviation from the norm. We believe that the synergy between the correct application of the CVS and the structured knowledge of the surgical anatomy in cholecystectomy helps the surgeon to handle non-typical structures safely and to complete the laparoscopic or open cholecystectomy without vascular–biliary injuries.

Aims: The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST. Methods: This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction. Results: Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences. Conclusions: These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC. [ABSTRACT FROM AUTHOR]

Background: The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice. Methods: A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes. Results: Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability. Conclusions: A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability. [ABSTRACT FROM AUTHOR]

Background: A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were "poor—unsafe", "adequate—safe", or "excellent—safe". Methods: A multi-national consortium of 12 expert LC surgeons applied the OPSA—LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet's AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of "poor—unsafe" vs. "adequate/excellent—safe". Results: Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00. Conclusions: The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation. [ABSTRACT FROM AUTHOR]

This study aims to present the results of a single surgeon's experience to demonstrate the effectiveness of the 'Critical View of Safety' (CVS) technique in preventing bile duct injuries in clinical practice. We retrospectively reviewed the records of 899 patients who underwent cholecystectomy using the CVS technique performed by a single surgeon at the Sivas Cumhuriyet University Hospital General Surgery Department between 2018 and 2023. Ethical approval for the study was obtained. Cholecystectomy cases were scanned retrospectively. The patients' age, gender, drain placement, surgery indications, and reason for switching to open cholecystectomy were recorded. Among the 899 patients reviewed, 312 were male (34.70%), and 587 were female (65.30%). The average age was 55.10 for males and 51,65 for females. It was determined that 7(0.77%), cases converted to open cholecystectomy. The most common indication for cholecystectomy was elective gallbladder stone removal, accounting for 47.05% of cases. No major bile duct injuries were detected.. The safe cholecystectomy technique can be safely applied to avoid bile duct injuries in laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Abstract Purpose Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons. Methods The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors’ experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed. Results The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia. Conclusions The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency.

Background: The Critical View of Safety (CVS) was proposed in 1995 to prevent bile duct injury during laparoscopic cholecystectomy (LC). The achievement of CVS was evaluated subjectively. This study aimed to develop an artificial intelligence (AI) system to evaluate CVS scores in LC. Materials and methods: AI software was developed to evaluate the achievement of CVS using an algorithm for image classification based on a deep convolutional neural network. Short clips of hepatocystic triangle dissection were converted from 72 LC videos, and 23,793 images were labeled for training data. The learning models were examined using metrics commonly used in machine learning. Results: The mean values of precision, recall, F-measure, specificity, and overall accuracy for all the criteria of the best model were 0.971, 0.737, 0.832, 0.966, and 0.834, respectively. It took approximately 6 fps to obtain scores for a single image. Conclusions: Using the AI system, we successfully evaluated the achievement of the CVS criteria using still images and videos of hepatocystic triangle dissection in LC. This encourages surgeons to be aware of CVS and is expected to improve surgical safety. [ABSTRACT FROM AUTHOR]

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16–80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC. [ABSTRACT FROM AUTHOR]

Background: Most bile duct (BDI) injuries during laparoscopic cholecystectomy (LC) occur due to visual misperception leading to the misinterpretation of anatomy. Deep learning (DL) models for surgical video analysis could, therefore, support visual tasks such as identifying critical view of safety (CVS). This study aims to develop a prediction model of CVS during LC. This aim is accomplished using a deep neural network integrated with a segmentation model that is capable of highlighting hepatocytic anatomy. Methods: Still images from LC videos were annotated with four hepatocystic landmarks of anatomy segmentation. A deep autoencoder neural network with U-Net to investigate accurate medical image segmentation was trained and tested using fivefold cross-validation. Accuracy, Loss, Intersection over Union (IoU), Precision, Recall, and Hausdorff Distance were computed to evaluate the model performance versus the annotated ground truth. Results: A total of 1550 images from 200 LC videos were annotated. Mean IoU for segmentation was 74.65%. The proposed approach performed well for automatic hepatocytic landmarks identification with 92% accuracy and 93.9% precision and can segment challenging cases. Conclusion: DL, can potentially provide an intraoperative model for surgical video analysis and can be trained to guide surgeons toward reliable hepatocytic anatomy segmentation and produce selective video documentation of this safety step of LC. [ABSTRACT FROM AUTHOR]

Background: The Tokyo Guidelines 2018 proposed fundus-first laparoscopic cholecystectomy (FFLC) as a bailout surgery. This study investigated the clinical impact of FFLC for severe cholecystitis. Methods: This study reviewed 772 patients who underwent laparoscopic cholecystectomy (LC) between 2015 and 2018. Of these patients, 171 patients were diagnosed with severe cholecystitis according to our difficulty scoring system. FFLC was not prevalent in our faculty for the first 2 years [early period group (EG)], whereas FFLC was predominantly used for the last 2 years [late period group (LG)]. There were 81 patients (47%) belonging to the EG and 90 patients (53%) in the LG. The clinical data and the surgical outcomes of these patients were retrospectively analyzed. Results: The difficulty score did not differ between the two groups (11 vs. 11 points, p = 0.846). Patients underwent FFLC significantly more frequently in the LG (63% vs. 12%, p = 0.020). Laparoscopic subtotal cholecystectomy (LSC) was done in 10 patients (11%) of the LG, which was significantly low compared to that in the EG (n = 20, 25%) (p = 0.020). In all patients, LC was safely achieved without bile duct injury or conversion to laparotomy. The incidence of choledocholithiasis was significantly low in the LG (0 vs. 4, p = 0.048). The median postoperative hospital stay was significantly shorter in the LG (6 vs. 4 days, p < 0.001). Conclusion: After the introduction of FFLC, there were significant improvements in the surgical outcomes of LC for severe cholecystitis, including the rate of LSC, incidence of choledocholithiasis, and duration of postoperative hospital stay. [ABSTRACT FROM AUTHOR]

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies. [ABSTRACT FROM AUTHOR]

Purpose: Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons. Methods: The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors' experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed. Results: The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia. Conclusions: The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency. [ABSTRACT FROM AUTHOR]

Introduction: Significant discrepancies exist between surgeon-documented and actual rates of critical view of safety (CVS) achievement on retrospective review following laparoscopic cholecystectomy. This discrepancy may be due to surgeon utilisation of the artery first technique (AFT), an exception to the CVS first described by Strasberg et al. The present study aims to characterise the use of the AFT, hypothesising it is used as an adjunct in difficult dissections to maximise exposure of the hepato-cystic triangle ensuring safe cholecystectomy. Methods: Prospective digital recording of the operative procedure of patients' undergoing laparoscopic cholecystectomy were undertaken at Christchurch Public Hospital, New Zealand and North Shore Private Hospital, Sydney, Australia. Videos were uploaded to Touch Surgery™ Enterprise. Difficulty was graded, annotated and indications for the AFT quantified using a standardised protocol. Results: A total of 275 annotated procedures were included in this study. The AFT was employed in 54 (20%) patients; in 13 (24%) patients for bleeding, in 35 (65%) patients where windows one and two were visible, and in 6 (11%) patients no windows were visible within the hepato-cystic triangle. There were significant differences in utilisation across operative grade and by seniority of operator (p < 0.005). Conclusions: The data presented here demonstrate the AFT is frequently used, particularly with Grade 3 cholecystectomy. However, more data are needed to confirm the utility and safety of this approach. Analysis of the AFT shows that to understand and improve safety in laparoscopic cholecystectomy appreciating how the operation was undertaken and not just that the CVS was achieved is crucial. [ABSTRACT FROM AUTHOR]

Background: The rate of bile duct injury in laparoscopic cholecystectomy (LC) continues to be high due to low critical view of safety (CVS) achievement and the absence of an effective quality control system. The development of an intelligent system enables the automatic quality control of LC surgery and, eventually, the mitigation of bile duct injury. This study aims to develop an intelligent surgical quality control system for LC and using the system to evaluate LC videos and investigate factors associated with CVS achievement. Materials and methods: SurgSmart, an intelligent system capable of recognizing surgical phases, disease severity, critical division action, and CVS automatically, was developed using training datasets. SurgSmart was also applied in another multicenter dataset to validate its application and investigate factors associated with CVS achievement. Results: SurgSmart performed well in all models, with the critical division action model achieving the highest overall accuracy (98.49%), followed by the disease severity model (95.45%) and surgical phases model (88.61%). CVSI, CVSII, and CVSIII had an accuracy of 80.64, 97.62, and 78.87%, respectively. CVS was achieved in 4.33% in the system application dataset. In addition, the analysis indicated that surgeons at a higher hospital level had a higher CVS achievement rate. However, there was still considerable variation in CVS achievement among surgeons in the same hospital. Conclusions: SurgSmart, the surgical quality control system, performed admirably in our study. In addition, the system's initial application demonstrated its broad potential for use in surgical quality control. [ABSTRACT FROM AUTHOR]

IntroductionSubtotal cholecystectomy is a type of surgical bail-out procedure indicated when facing difficult laparoscopic cholecystectomy due to not reaching the critical view of safety, inadequate identification of the anatomical structures involved and/or risk of injury.Materials and methodsA comprehensive search on PubMed were performed using the following Mesh terms: Subtotal cholecystectomy and Partial cholecystectomy. The PubMed databases were used to search for English-language reports related to Subtotal cholecystectomy between January 1, 1987, the date of the first published laparoscopic cholecystectomy, through January 2023. 41 studies were included.ResultsSubtotal cholecystectomy's incidence oscillates between 4.00% and 9.38%. Strasberg et al., divided subtotal cholecystectomies in “fenestrating” and “reconstituting” types based on if the remaining portion of the gallbladder was left open or closed. Subtotal cholecystectomy can sometimes be a challenging procedure and is associated to a high rate of complications such as biliary fistula, retained gallstones, subhepatic or subphrenic collections, among others.ConslusionSubtotal cholecystectomy is a safe alternative when facing difficult cholecystectomy in which the critical view of safety is not reached in order to avoid complications. A classification system should be implemented in surgical descriptions to compare the different surgical techniques employed. In order to avoid bile leakage and cholecystitis of the remnant gallbladder, the surgical technique must be performed skillfully. There is still a current lack of information on alternative techniques such as omental plugging or falciform patch in order to judge their utility. There needs to be further research on long-term complications such as malignancy of the remnant gallbladder.

Purpose: Bile duct injury (BDI) remains the most serious complication following cholecystectomy. However, the actual incidence of BDI in the Czech Republic remains unknown. Hence, we aimed to identify the incidence of major BDI requiring operative reconstruction after elective cholecystectomy in our region despite the prevailing modern 4 K Ultra HD laparoscopy and Critical View of Safety (CVS) standards implemented in daily surgical practice among the Czech population. Methods: In the absence of a specific registry for BDI, we analysed data from The Czech National Patient Register of Reimbursed Healthcare Services, where all procedures are mandatorily recorded. We investigated 76,345 patients who were enrolled for at least a year and underwent elective cholecystectomy during the period from 2018–2021. In this cohort, we examined the incidence of major BDI following the reconstruction of the biliary tract and other complications. Results: A total of 76,345 elective cholecystectomies were performed during the study period, and 186 major BDIs were registered (0.24%). Most elective cholecystectomies were performed laparoscopically (84.7%), with the remaining open (15.3%). The incidence of BDI was higher in the open surgery group (150 BDI/11700 cases/1.28%) than in laparoscopic cholecystectomy (36 BDI/64645 cases/0.06%). Furthermore, the total hospital stays with BDI after reconstruction was 13.6 days. However, the majority of laparoscopic elective cholecystectomies (57,914, 89.6%) were safe and standard procedures with no complications. Conclusion: Our study corroborates the findings of previous nationwide studies. Therefore, though laparoscopic cholecystectomy is reliable, the risks of BDI cannot be eliminated. [ABSTRACT FROM AUTHOR]

Background: The critical view of safety (CVS) is the gold standard for performing safe cholecystectomies and minimizing common bile duct (CBD) injuries. It requires three criteria: complete clearance of the hepatocystic triangle, partial separation of the gallbladder from the cystic plate, and two structures alone entering the gallbladder. However, biliary anatomy varies widely, with frequent aberrant arterial supplies, which can mislead or disorient those attempting to acquire the CVS. This study was designed to examine the nature and frequency of cystic artery anatomic anomalies.Methods: We conducted a prospective observational study from 2018 to 2020, compiling photos of the critical view of safety of 100 consecutive elective cholecystectomies performed at our institution. Gallbladders were dissected up to the parallel portion of the cystic plate to achieve a critical view of safety. All tubular structures were preserved and clipped. Operative reports were examined for mention of posterior cystic arteries or aberrant arterial supplies. Photos were reviewed for an adequate critical view of the safety and presence of aberrant arterial supplies. The rate of aberrant arterial supply was determined and photos were reviewed for patterns of common abnormalities.Results: There were 121 patients who underwent an elective cholecystectomy; 21 lacked intraoperative pictures and were excluded from the study. Of the 100 patients included, 57 (57%) had an aberrant arterial supply with more than one cystic artery; seven had three concurrent arteries. Of those with more than one cystic artery, 21% had a recurrent cystic artery, 21% had a posterior dominant cystic artery, and 12% had a low-branching anterior cystic artery.Conclusion: Even with appropriate dissection for the CVS, surgeons can expect to frequently visualize more than two structures entering the gallbladder when a posterior cystic artery is present. It is, therefore, integral to distinguish this aberrant anatomy to prevent inadvertent injury to the CBD. [ABSTRACT FROM AUTHOR]

Background The critical view of safety (CVS) is a critical technique to minimize the risk of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). This study evaluated the rate of CVS achievement and examined factors influencing its success. Methods This prospective study included 97 patients undergoing LC. Data on demographic characteristics, preoperative factors, surgical difficulty, and surgeon experience were collected. CVS achievement was assessed using Strasberg's criteria, and associated factors were analyzed. Results CVS was successfully achieved in 31 of 97 cases (32%), while it was not achieved in 66 cases (68%). Factors significantly associated with failure to achieve CVS included previous abdominal surgery (p = 0.024), prior endoscopic retrograde cholangiopancreatography (ERCP) (p = 0.024), acute cholecystitis (p = 0.024), and higher difficulty grades according to the modified Nassar scale (p < 0.001). Although there was no statistically significant difference in CVS achievement between specialists and residents (p = 0.223), specialists had a higher success rate (37.5%) compared to residents (28%). Achieving CVS was associated with shorter operative times (mean: 60 vs. 70 minutes, p < 0.001) and reduced use of postoperative drains (16.1% vs. 83.9%, p < 0.001). Importantly, no BDIs were observed. Conclusion Achieving CVS remains a challenge, particularly in complex cases and patients with prior abdominal interventions or acute inflammation. Enhanced surgical training, meticulous preoperative planning, and the use of adjunctive technologies may improve CVS success rates and contribute to safer outcomes in LC., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alnoor et al.)

In this article, we discuss preoperative clinical evaluation, diagnostic considerations, and the role/choice of antibiotics. Operative planning is discussed with attention to patient characteristics/disease condition as they may inform consideration of alternative operative approaches. Detailed steps of laparoscopic, robotic-assisted, and open cholecystectomy are discussed. Indications and operative steps for intraoperative cholangiogram and laparoscopic transcystic common bile duct exploration are included. We conclude with postoperative care, including evaluation of common complications and necessary management considerations., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Although single-incision robotic cholecystectomy (SIRC) overcomes various limitations of single-incision laparoscopic cholecystectomy (SILC), it is associated with high cost. In this study, we intended to investigate if SIRC is recommendable and advantageous to patients despite its high cost. Materials and Methods: We prospectively collected and analysed data of patients who had undergone either SILC (n = 25) or SIRC (n = 50) for benign gallbladder diseases, with identical inclusion criteria, between November 2017 and February 2019. Results: SILC and SIRC showed similar operative outcomes in terms of intra- and post-operative complications and verbal numerical rating scale (VNRS) for pain. However, the SIRC group exhibited significantly longer operation time than the SILC group (83.2 ± 32.6 vs. 66.4 ± 32.8, P = 0.002). The SIRC group also showed longer hospital stay (2.4 ± 0.7 vs. 2.2 ± 0.6, P = 0.053). Although the SILC and SIRC groups showed no significant difference in VNRS, the SIRC group required a higher amount (126.0 ± 88.8 mg vs. 87.5 ± 79.7 mg, P = 0.063) and frequency (3.0 ± 2.1 vs. 2.0 ± 1.8, P = 0.033) of intravenous opioid analgesic administration. During surgery, the critical view of safety (CVS), the prerequisite for safe cholecystectomy, was identified in only 24% (n = 6) of patients undergoing SILC and in 100% (n = 50) of patients undergoing SIRC (P < 0.05). Conclusion: We conclude that although SILC and SIRC have similar operative outcomes, SIRC is advantageous over SILC because of its potential to markedly enhance the safety of patients by proficiently acquiring CVS.

Introduction: Since the establishment of the Critical view of safety (CVS), different strategies have been created such as bailout procedures (SC, subtotal cholecystectomy), classifications for preoperative and intraoperative complexity (The Parkland grading scale, PGS) and objective evaluation of the CVS (doublet score, DS) to establish a "Culture of Safety in Cholecystectomy, COSIC"; to avoid complications. Methods: A multiple choice questionnaire was applied to residents and graduated surgeons from different Hospitals in Mexico during different national meetings; evaluating the knowledge of this different concepts (CVS, SC, PGS, DS), univariate logistic regression was used to assess the association of the knowledge with adverse events (AE) like the Bile duct injury. Results: A total of 744 questionnaires were evaluated; 284 (38.17%) women and 460 (61.83%) men; 436 (58.6%) were residents and 308 (41.4%) graduated surgeons. 708 (95.16%) reported knowing the CVS; however, only (51.98%, p ≤ 0.001) defined the concept correctly, while 136 (18.28%) reported knowing the DS, but only 44 (5.91%) defined it correctly. Regarding the PGS, 398 (53.49%) mentioned knowing it, but only 262 defined it correctly. The concept of SC 642 (86.29%) reported knowing it; however, only (56.7%, p ≤ 0.001) correctly defined the techniques, being the reconstituting technique the preferred one (42.37% vs 34.89%). In this survey, the correct knowledge of the CVS (OR 0.47, p < 0.001), the subtotal techniques (OR 0.71 p = 0.07), the DS (OR 0.48 p < 0.001) and of the PGS (OR 0.28, p < 0.001) decreased the risk of presenting BDI. Conclusion: Despite the COSIC and the timing of publication of the CVS; the percentage of people who can correctly define basic safety concepts is low among residents and licensed surgeons. Therefore, it is important to emphasize the dissemination of these concepts to obtain safe LC and thus reduce the incidence of complications. [ABSTRACT FROM AUTHOR]

Background: A computer vision (CV) platform named EndoDigest was recently developed to facilitate the use of surgical videos. Specifically, EndoDigest automatically provides short video clips to effectively document the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). The aim of the present study is to validate EndoDigest on a multicentric dataset of LC videos. Methods: LC videos from 4 centers were manually annotated with the time of the cystic duct division and an assessment of CVS criteria. Incomplete recordings, bailout procedures and procedures with an intraoperative cholangiogram were excluded. EndoDigest leveraged predictions of deep learning models for workflow analysis in a rule-based inference system designed to estimate the time of the cystic duct division. Performance was assessed by computing the error in estimating the manually annotated time of the cystic duct division. To provide concise video documentation of CVS, EndoDigest extracted video clips showing the 2 min preceding and the 30 s following the predicted cystic duct division. The relevance of the documentation was evaluated by assessing CVS in automatically extracted 2.5-min-long video clips. Results: 144 of the 174 LC videos from 4 centers were analyzed. EndoDigest located the time of the cystic duct division with a mean error of 124.0 ± 270.6 s despite the use of fluorescent cholangiography in 27 procedures and great variations in surgical workflows across centers. The surgical evaluation found that 108 (75.0%) of the automatically extracted short video clips documented CVS effectively. Conclusions: EndoDigest was robust enough to reliably locate the time of the cystic duct division and efficiently video document CVS despite the highly variable workflows. Training specifically on data from each center could improve results; however, this multicentric validation shows the potential for clinical translation of this surgical data science tool to efficiently document surgical safety. [ABSTRACT FROM AUTHOR]

TG18 recommends bailout surgery (BOS) for difficult laparoscopic cholecystectomy. However, there is not a clear criterion on the decision process on whether to continue laparoscopic BOS or open BOS, and optimal procedure for treatment for the remnant cystic bile duct also awaits discussion. We comparted with open BOS and laparoscopic BOS, and compared with suture close and clipping or ligating of remnant cystic duct. We have accrued 57 patients underwent BOS during study period. Seventeen cases underwent laparoscopic BOS, and 38 cases underwent open BOS. There were 22 patients were accrued in suture closing and 35 patients were accrued in clipping or ligating. Open BOS experienced high levels of CRP, WBC, NLR, and CAR, and was associated with significantly longer hospitalization, operating time, and amount of bleeding. Suture close was higher in patients with preoperative endoscopic lithotripsy (EL). BOS can be sufficiently performed under laparoscopy. Patients underwent preoperative EL tended to be higher necessity to suture close of cystic duct. [ABSTRACT FROM AUTHOR]

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms ”difficult cholecystectomy”, ”bile duct injuries”, ”safe cholecystectomy”, and ”laparoscopy in acute cholecystitis”. The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.