For patients with Grade III (severe) acutecholecystitis, appropriate organ support, in addition to initial medical treatment, is necessary. In such situations, urgent or early gallbladder drainage is recommended. 1 Elective chol- ecystectomy can be performed after treating the acute in- flammatory process. 13 Although an operation within the golden 72 hours from symptom onset has been suggested, early surgery is not always possible in clinical practice due to logistic difficulties in performing an emergency surgery for such patients. 10,19-21 Furthermore, emergency surgical procedures could lead to serious complications in high-risk patients. 10
In this study, the surgicaloutcomesof nSILC were comparable with those of CLC. Although port site complications occurred more in nSILC group, there was no significant difference in operation time, occurrence rate of perioperative complication, and length of hospital stay. In subgroup analysis performed in each surgical difficulty, the surgicaloutcomesof nSILC were comparable with those of CLC not only in easy group but also in difficult group. These results mean that our technique (nSILC) using auxiliary needlescopic grasper can be applied safely not only in selective patients, but also in difficult cases.
Backgrounds/Aims: Laparoscopic cholecystectomy is the best treatment choice foracutecholecystitis. However, its higher conversion rate and postoperative morbidities remain controversial. The purpose of this retrospective study is to evaluate the clinical significance oflaparoscopiccholecystectomy that is performed at our institution in patients with acutecholecystitis. Methods: Between January 2003 and December 2009, a retrospective study was carried out for 190 cases ofacutecholecystitis undergoing laparoscopiccholecystectomy at our institution. They were divided into 2 groups, based on the time of operation from the onset of the symptom and other previous abdominal operation history. These groups were compared in the conversion rate and perioperative clinical outcomes, such as sex, age, accompanied disease, operation time, complications, postoperative hospital stay, total hospital stay and total costs.
open surgery for patients with poor pulmonary function. 19 When performing LSC forsevereacutecholecystitis, suspected malignancy prior to operation with imaging studies such as CT and MRI (magnetic resonance imag- ing) should never be made light of. Open conversion is mandatory when malignancy is demonstrated during LSC. 17 Furthermore, serial ultrasonography, CT, MRI, ERCP, and serum tumor markers should be carried out to follow-up on signs of malignancy. The LSC group in this study had a mean follow-up period of 2.3 months af- ter operation, during which no remnant gallbladder pro- gressed to carcinoma. There was one case in the LC group who suffered from postoperative cholangitis due to bile duct obstruction, for which examination was carried out to reveal a distal common bile duct cancer. The patient underwent pylorus preserving pancreatoduodenectomy. So far, there have not been any reports of remnant GB after LSC progressing to carcinoma. Yet, due to the short fol- low-up period, this cannot be confirmed and thus, further studies with longer follow-up periods are necessary.
Indeed, stereopsis is important, especially for tasks requir- ing fine manipulative skills and spatial discriminations, such as threading a needle or surgeries with minimal ac- cess like laparoscopic surgeries. 20,21 Stereopsis and depth perception are not synonymous. Monocular clues includ- ing object overlap, relative object size, highlights and shadows, motion parallax, and perspective contribute to depth perception. 22 However, stereopsis is the highest form of binocular cooperation, and it adds a new quality to vision 22 that is accomplished by bichannel optical sys- tems rather than single-channel optic systems. We used a dual-lens laparoscope in our studies. Previous studies showed that when contrast was the same in the 2 eyes, binocular acuity was better than best monocular acuity by an average of 0.045 log minimum angle of resolution, or 11%, 23,24 which means that normal binocular vision im- proves functional vision by binocular summation and stereopsis. 19 Therefore, using the bichannel optical system, the surgeon has a heightened spatial perception and can work faster and more safely than with a single-channel system. 25 Moreover another study comparing the 3D and 2D system by using dual lenses evaluated only the oper- ation time of LC. 26 Effect of the 3D system on the per- formance of the surgeon and its utility as and educational tool forlaparoscopic surgery has also been highlighted in the literature. 2,5,6,10
In the present study, patients with complicated chol- ecystitis were found to have had moderate to severe in- flammation and poor general conditions. Most current sur- geons agree that LC is the treatment of choice for compli- cated cholecystitis. Nevertheless, there are two issues on the high rate of complications after surgery and open-con- version after LC in high-risk patients with complicated cholecystitis. Thus, to reduce the incidence of complica- tions and the open-conversion rate, various studies have been reported on the appropriate timing of the surgery.
port robotic cholecystectomy on patients’ surgical pain, post
operative complications and satisfaction.
Patients with gallbladder disease such as acute or chronic cholecystitis, cholelithiasis, or gallbladder polyp, who visited the department of gastrointestinal surgery at Kangbook Samsung Medical Center were recruited. Of those patients who were scheduled to under go either LC or RC, candidates were selected based on the American Society of Anesthesiologists physical status classi fi ca tion system, which is used to determine whether anesthesia can be used on patients during surgery. The participants selected for this study were classified as class I, defined as healthy patients without systemic disturbances, or as class II, defined as patients with moderate systemic disturbances caused by gallbladder disease or other existing pathological processes. Patients diagnosed with gallbladder cancer or at risk of bleeding were excluded. Both LC and RC used transumbilical approach with one 5mm trocar for LC and two 12mm trocars for RC.
PTGBD procedure and patient selection
The PTGBD procedure was performed under local anesthesia using ultrasonography by an interventional radiologist.
Fluoroscopy followed to confirm the guidewire placement in the gallbladder, and one of 8 to 10French pigtail catheters was used. The transhepatic approach was preferred in our cases. We performed PTGBD for patients who had suffered from severe abdominal pain, tenderness or fever originating from distension and gangrenous change of gallbladder, but not ruptured in radiologic findings. Also, laboratory findings showed inflammation such as leukocytosis representing acutecholecystitis.
Although this reduces the out-of-pocket payment for pa- tients, it does not eliminate it entirely and hence patients were still concerned with the hospital bill. With inflating healthcare costs, it is worthwhile for doctors and policy- makers to consider how to reduce hospital costs while maintaining the standard of care. A study at our institution for the treatment ofacutecholecystitis found significant cost advantage of early LC over interval LC, predom- inantly due to the reduced hospital length of stay and in- vestigation costs. 36 Similar findings were reported in the UK by Sutton et al. foracute gallbladder pathologies, in- cluding biliary colic, acutecholecystitis, and gallstone pancreatitis, favouring emergent over delayed LC. 37 From a healthcare provider perspective, it is worth looking into measures to increase the rate of early or emergent LC for such cases, to eventually pass on these healthcare savings to patients. Waiting time was not a significant factor for patients at our institution, likely because most patients were able to be scheduled for elective LC within eight weeks from the date of consultation.
Index admission cholecystectomy has been established as a standard of care in patients with AC. 31 TG13 recom- mends early cholecystectomy in mild and certain moder- ate AC. 1 We have previously reported that TG13 can be restrictive and patients with moderate or severe AC can also be safely treated with index admission cholecystectomy. 32 In our current study also more than two thirds of patients had moderate or severe AC. A Cochrane review reporting on six clinical trials including 488 patients with AC and comparing index admission LC with interval LC concluded that index admission LC does not positively influence bile duct injury, serious complica- tions and conversion to open cholecystectomy. 31 None of the trials studied QoL outcomes and the only benefit ob- served was in reduction in length of hospital stay.
many RCTs. Nevertheless, prophylactic antibiotics are recommended for the high-risk group. In defining the high-risk group, both guidelines acknowledge bile spillage (intraoperative gallbladder rupture), conversion to lapa- rotomy, acutecholecystitis, jaundice, pregnancy, im- munosuppression, and insertion of a prosthetic device. 12,13 But, intraoperative cholangiogram is considered to be a high-risk only in the SIGN guideline. In the therapeutic guideline by ASHP, the high-risk factors for SSI are con- sidered to be: emergency procedures, diabetes, long proce- dure duration, age ＞70 years, ASA score of 3 or higher, and an episode of colic within 30 days before the procedure.
Paraduodenal hernia is a rare congenital malformation. Management consists of reduction of the herniated intestine and repair of the defect. A 74-year-old woman presented to the Emergency Department with persistent right upper quadrant pain that began 3 hours ago. Physical examination revealed tenderness at right upper quadrant of abdomen. Computed tomography revealed multiple gallstones with gallbladder wall thickening, marked dilatation of stomach and duodenum and a sac-like mass of small bowel loops to left of ligament of Treitz suggesting acutecholecystitis and left paraduodenal hernia. Laparoscopic exploration of abdomen was performed and cholecystectomy, bowel reduction, and closure of defect with intracorporeal interrupted suturing were performed. For left paraduodenal hernia without bowel necrosis, laparoscopic reduction of incarcerated bowel and closure of hernial orifice are technically feasible and may be the surgical method of choice because of its minimal invasiveness and aesthetic advantage.
Experience with partial cholecystectomy in severecholecystitis
Department of Surgery, Sanbon Hospital, Wonkwang Univiversity, Kunpo, Korea
Backgrounds/Aims: Partial cholecystectomy (PC) is often an inevitable operative procedure when Calot triangle is se- verely inflamed and fibrosed with conglomerated structures. We reviewed our clinical outcomesof PC to compare its feasibility with conventional total cholecystectomy (TC), especially for its possible application to laparoscopic procedure. Methods: From Aug. 2000 to July 2008, 20 cases of PC by laparotomy were performed, including converted cases during laparoscopiccholecystectomy. Sixty-eight cases of TC by open method during the same period were compared in a mean follow-up period of 108 months. Results: Bile fistula was observed in 3 cases of PC; one case needed endoscopic biliary stent for management and a second case showed fistula that closed by supportive care in 2 months. The last patient died from peritonitis. No bile fistula was observed in PC. Morbidities were found in 9 cases of PC (45%) and in 11 cases of TC (16.2%). Bile fistula (n=3) and wound infection (n=3) were prominent in the PC group, and wound infection (n=7) in the TC group. Reoperations were necessary for 5 (25.0%) and 4 (5.9%) patients from PC and TC, respectively. Mortality occurred in 2 (2/10 10%) and 4 cases (4/68 5.9%) of PC and TC, respectively. Two mortalities in each group resulted from direct extension ofcholecystitis. Conclusions: Considering the higher risks of complications and mortality, PC should be avoided as long as possible, and patients should always be informed of its clinical outcomes postoperatively. Further elaboration of a safer operative plan should be sought.
than SILC. In other words, SILC should be performed by patient selection based on the degree of inflammation of the gallbladder.
When the SILC and CLC groups are retrospectively an- alyzed, patients who underwent SILC in our center were younger, included a higher percentage of women, and had more cases of chronic cholecystitis than acute chol- ecystitis or empyema in the postoperative gallbladder pathology. Patients who had upper abdominal surgical his- tory prior to surgery or who underwent PTGBD insertion were more likely to undergo CLC than SILC, and acutecholecystitis and empyema were more frequently observed in the postoperative pathology. This finding suggests that patients who have good morphology, female patients who may highly regard cosmetics, and patients who do not have severe inflammation were mainly selected for SILC in our center. In fact, patients with abdominal surgical his- tory may have severe adhesion in their abdomen and a high bleeding risk when they undergo SILC, which re- quires many techniques, and as a result, the operation time may become longer. Therefore, CLC may be preferred over SILC or additional port insertion may be inevitable during SILC. Sato N. et al. argued that the factors that may require additional port insertion during SILC were gender, prior history of upper abdominal surgery, and white blood cell count. 20
Results: Of the 739 patients, 458 were for grade I AC, and 281 were for grade II/III AC. In grade I AC, the cut-off value for the rela- tionship between duration A and PIO was 4.5 days. The cut-off value for the relationship between duration B and PPO was 7.5 days. In multivariate analysis, duration A ≥ 5 days and duration B ≥ 8 days were statistically significant predictors for DS and PPO, respective- ly. In grade II/III AC, the cut-off value for the relationship between duration A and PPO was 2.5 days. In multivariate analysis, dura- tion A ≤ 2 days was statistically significant predictor for PPO.
Introduction: Gallstone disease is common morbidity in elderly (age ≥ 65 years old). Laparoscopic cholecystectomy is increasingly performed in an ever elderly. However, there are no clarified standards for treatment for asymptomatic cholelithiasis in elderly. The purpose of this study was to compare postoperative outcomesof elderly with those of younger populations and to suggest an appropri- ate age for preventive cholecystectomy before the risk increases.
During cholecystectomy, care should be taken to avoid perforating the gallbladder. Bile spillage during laparo- scopic cholecystectomy can provoke tumor recurrence in patients with a hidden malignancy of the gallbladder. 17 Many reports have shown that bile spillage negatively af- fects progression free survival in patients with incidental gallbladder cancer discovered during laparoscopic cho- lecystectomy. 18-20 Moreover, bile spillage is a risk for sur- gical site infection. Peponis et al. 21 reported that patients who experience bile spillage are over two times more likely to develop surgical site infection. Moreover, Rice et al. 22 reported that intraperitoneal bile spillage during laparoscopiccholecystectomy was associated with in- tra-abdominal abscesses. Bile spillage has been associated with old age, high body weight index, and the presence of omental adhesions, 21,22 which indicates that bile spill- age can be an indicator ofsurgical stability. In our study, we found bile spillage to be more common in SILC patients.
Thank you for publishing our article titled “Comparison of the outcomesof robotic cholecystectomy and laparoscopiccholecystectomy” in July issue 2017 (Ann Surg Treat Res 2017;93:27-34). In the original publication, we found a mistake in funding statement. We performed this study supported by grants from Kangbuk Samsung Hospital. Also in the title page (1st affiliation) and main text, we would like to revise the affiliation name from Kangbook Samsung Medical Center to Kangbuk Samsung Hospital. At the time of submission, we checked this, but it missed at the publication. We forgot to check it at correction period. The mistake was not due to the editorial office of Annals of Surgical Treatment and Research. We attached a corrigendum along with this letter to request for change organization.
(n=40) of them will need an operation within 6 weeks due to recurrent symptoms, and the other 56.5% (n=52) can be observed at home while they remain in a symptom-free state. Additionally, we can presume that when operation is delayed in grade I patients, as shown in Table 1 and 3, the success rate oflaparoscopic operation will gradually rise and the complication rate will fall gradually, as the operation timing is delayed. The difference in the open conversion rate between eLC and dLC was remarkable, 7.7% and 20.5% respectively, with an average rate of 16.1% for total grade I patients. We could not, however, review the number of times the patient experienced symp- toms in the past nor review the full treatment history be- fore the patient came to our hospital, factors which can obscure the nature of the severity of symptoms and the best timing for the operation.
We retrospectively reviewed patients treated with SILC in our institution. This study included total of 697 patients initially diagnosed with benign GB diseases including acutecholecystitis, chronic cholecystitis, symptomatic GB stone, polyp, adenomyomatosis and empyema between April 2010 and July 2014. In this study, we excluded patients with suspected earlystaged GB malignancy and with concurrent cardiopulmonary disorder who strongly expected perioperative morbidity. Between October 2010 and September 2012, we have performed SILC using the Konyang standard method based on the 3channel method. Since then, we have performed SILC using the Modified Konyang standard method based on the 4channel method. All operations were performed by two surgeons. We reported patient demography including Age (<80 years old or ≥80 years old), sex, body mass index (BMI,