Three Port Laparoscopic Cholecystectomy by a Modified Technique

Introduction:Since the introduction of laparoscopic cholecystectomy (LC) several modifications have been introduced to its procedure. Main aim of these modifications is to improve cosmesis & reduce pain. Several institutes are routinely performing conventional 3 ports laparoscopic. In modified 3 ports LC, the third port was moved from right hypochondrium to umbilicus, to conceal it in the umbilical scar, thereby giving the three port comfort to the surgeon and two port benefits to the patient. Methods: This observational study was conducted in the Department of Surgery of Shaheed Suhrawardy Medical College & Hospital from September 2015 to October 2016. After taking valid consent a total 45 patients were selected for modified 3 ports LC. Here we tried to see the safety and benefit of this modified technique by assessing operating time, intra-operative complications, open conversion rate, postoperative wound infection, post-operative hospital stay, pain score and satisfaction with cosmetic outcome. Results: 3 patients were excluded from study due to different reasons. So, among total 42 (N) patients 30 (71.4%) were female & 12 (28.6%) were male. Operative time was 58.48 ± 32.52 minutes (range 34 to 180 minutes). 2 patients required conversion to open surgery. Pain score was 2.07 ±1.71 and cosmetic score was 8.67 ± 1.99. Conclusion: Modified 3 port laparoscopic cholecystectomy can be performed safely with a higher cosmetic satisfaction in selected cases by expert surgeon. J Shaheed Suhrawardy Med Coll 2020; 12(2): 90-94

Midterm outcomes of 455 patients receiving the AFX2 endovascular graft for the treatment of abdominal aortic aneurysm: A retrospective multi-center analysis

Since being introduced into clinical practice the AFX family of endografts has undergone labelling updates, design and manufacturing changes to address a Type III failure mode. The published literature on the performance of the current endograft–AFX2 –is limited to small series with limited follow up. The present study reports the largest series of patients implanted with AFX2 for the treatment of abdominal aortic aneurysms. The study was a retrospective, 5 center study of patients receiving an AFX2 endograft from January 2016 until Dec 2020. Electronic case report forms were provided to four of the centers, with one additional site providing relevant outcomes in an independent dataset. Relevant outcomes were reported via Kaplan-Meier analysis and included all-cause mortality, aneurysm-related mortality, post EVAR aortic rupture, open conversion, device related reinterventions and endoleaks. Among a cohort of 460 patients, 405 underwent elective repair of an AAA, 50 were treated for a ruptured AAA, and 5 were aorto-iliac occlusive disease cases. For the elective cohort (mean age 73.7y, 77% male, mean AAA diameter 5.4cm), the peri-operative mortality was 1.7%. Freedom from aneurysm-related mortality was 98.2% at 1,2,3 and 4 years post-operatively, there were no post-operative aortic ruptures, and 2 patients required open conversion. Freedom from Type Ia endoleaks was 99.4% at 1, 2, 3 and 4 years. Freedom from Type IIIa and Type IIIb endoleaks were 100% and 100% (year 1), 100% and 99.6% (year 2), 99.4% and 99.6% (year 3), 99.4% and 99.6% (year 4) respectively. Freedom from all device-related reintervention (including Type II endoleaks) at 4 y was 86.8%. The AFX2 endograft appears to perform to a satisfactory standard in terms of patient centric outcomes in mid-term follow up. The Type Ia and Type III endoleaks rates at 4y appear to be within acceptable limits. Further follow up studies are warranted.

A comparison of surgical practice and operative outcomes between retroperitoneal and transperitoneal laparoscopic nephrectomies – 6 years of data from the BAUS Nephrectomy database

Objectives: While the choice of surgical approach for laparoscopic nephrectomy is broadly split between transperitoneal and retroperitoneal options, the evidence for the impact of this decision on perioperative outcomes is built on relatively small volume data, with often inconsistent findings and conclusions. We aimed to assess the impact of operative approach on perioperative outcomes for laparoscopic radical, partial and simple nephrectomy and nephroureterectomy through analysis of the British Association of Urological Surgeons (BAUS) Nephrectomy database. Patients and methods: All patients added to the BAUS Nephrectomy database with laparoscopic surgery between 2012 and 2017 inclusively were included and subdivided by operation and surgical approach. Preoperative patient and tumour characteristics, as well as intraoperative and post-operative short-term outcomes, were assessed. Results: Overall, 26,682 operations were documented over the review window (81.6% transperitoneal). Small increases in blood loss ( p = 0.001), transfusion rate ( p = 0.02) and operative length ( p = 0.01) were seen for transperitoneal radical nephrectomies and longer hospital stays seen for retroperitoneal procedures (radical nephrectomy p = 0.00l; partial nephrectomy p = 0.04). Retroperitoneal procedures were associated with increased rates of conversion for simple nephrectomy ( p = 0.02), nephroureterectomy ( p = 0.03) and most notably partial nephrectomy (10.5% versus 4.4%; p = 0.001). No further variation in intraoperative complications, post-operative complications, tumour margin positivity rates, unintended ITU admission, or likelihood of death was identified related to surgical approach. Conclusion: Observed variations in perioperative outcomes were generally modest in nature, and little ground is seen to support a change in operative technique for those committed to one approach. A caveat to this exists with open conversion for retroperitoneal partial nephrectomies and requires careful consideration of patient selection by the individual surgeon. Level of evidence: 4

P-BN62 Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after acute biliary presentation

Background Laparoscopic cholecystectomy is introduced as a treatment option for symptomatic gall bladder disease in 1987 and it is now the gold standard treatment for symptomatic gall bladder disease. The rate of conversion from laparoscopic to open ranges between 5 and 10% .The step of paramount importance in cholecystectomy is the clear identification of the cystic duct and artery, which in some situations can be difficult especially in presence of dense adhesions or severely inflamed gall bladder, increasing the risk for common bile duct (CBD) injury. The traditional response to encountering a difficult laparoscopic cholecystectomy procedure is to perform conversion to an open procedure but the open conversion has its drawbacks; The subtotal cholecystectomy has been shown to reduce the need for conversion to an open procedure, thus reducing complications associated with the open cholecystectomy. Studies have also shown that this procedure decreases the bile duct injury rate . Subtotal cholecystectomy rates increased nationally over the past decade. The aim of our study is to identify factors which could predict the need for a subtotal cholecystectomy in the acute biliary admission group having delayed elective Laparoscopic cholecystectomy ,hence proper planning in terms on theatre timing, expertise and patients consenting Methods We conducted a retrospective analysis of patients who had delayed elective laparoscopic subtotal cholecystectomy after admission with Acute Biliary disease and managed conservatively in a tertiary London hospital, between 01/03/2019-29/02/2020 We collected data for all patients whose primary diagnosis was either Acute Cholecystitis, Cholelithiasis, Ascending Cholangitis, Choledocholithiasis and Gallstone Pancreatitis, and analysed these in terms of patient demographics, , duration of index admission, laboratory and radiological results during the acute admission and need to intervention during the acute phase either as a drain (cholecystostomy) or ERCP during initial management. Data were collected from electronic patient records, regarding age, gender, indication for surgery, operative notes, preoperative gall bladder wall thickness on US scan, laboratory results during acute admission. BMI, other interventions such as endoscopic retrograde cholangiopancreatography (ERCP) and cholecystostomy Odds ratios were calculated to assess the risk of patients having a subtotal cholecystectomy. Results 243 patients presented between 01/03/19-29/02/2020 which acute biliary pathology – 95 Male and 148 Female, 230 patients had delayed elective laparoscopic cholecystectomy at least 6 weeks post-acute admission Of 230 laparoscopic cholecystectomies, 22 (9.56%) cases had a subtotal cholecystectomy 13(59.9%) patients were male patients, median age 72 (54.5%) had BMI more than 30 No open conversion. The indication for cholecystectomy in the subtotal group was as follows: Acute cholecystitis 12 (54.54%), Ascending cholangitis 4 (18.18%), Choledocholithiasis 3(13.63%), gall stone pancreatitis 1(4.5%), Cholelithiasis 2 (9.09%)The subtotal cholecystectomy group had Gall bladder wall thickness during index admission documented 4 (18.18%)patients had Gall bladder wall thickness less than 4 or equal 4 mm, 18(81.81%) patients had Gall bladder wall thickness more 4 mm. Odds ratios were calculated to assess the correlation between several characteristics and the likelihood of having a subtotal cholecystectomy in the delayed elective cholecystectomy, we concluded that Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC > 15000 during acute admission, all increased the likelihood of having a subtotal cholecystectomy Conclusions Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC > 15000 during acute admission all increased the likelihood of having a subtotal cholecystectomy. We recommend all these information should be documented during planning for laparoscopic cholecystectomy to allow proper theatre time planning and patient consenting for the possibility of having a subtotal cholecystectomy.

Emergency Surgery Admissions and The COVID-19 Pandemic: Did The First Wave Really Change Our Practice? Results of An ACOI/WSES International Audit On 6263 Patients.

IntroductionThe COVID-19 pandemic is having a deep impact on emergency surgical services, with a significant reduction of patients admitted into emergency surgical units world widely. Reliable figures of this reduction have not been produced yet. Our international audit aimed at giving a precise snapshot of the absolute and relative changes of emergency surgical admissions at the outbreak of the pandemic. Materials and methodsDatasets of patients admitted as general surgical emergencies into 45 internationally distributed emergency surgical units during the months of March and April 2020 (Covid-19 pandemic outbreak) were collected and compared with those of patients admitted into the same units during the months of March and April 2019 (pre-Covid-19). Primary endpoint was to evaluate the relative variation of the presentation symptoms and discharge diagnoses between the two study periods. Secondary endpoint was to identify the possible change of therapeutic strategy during the same two periods. ResultsForty-four centres participated sent their anonymised data to the study hub, for a total of 6263 patients. Of these, 3810 were admitted in the pre-Covid period and 2453 in the Covid period, for a 35.6% absolute reduction. The most common presentation was abdominal pain, whose incidence did not change between the two periods, but in the Covid period patients presented less frequently with anal pain, hernias, anaemia and weight loss. ASA 1 and low frailty patients were admitted less frequently, while ASA>1 and frail patients showed a relative increase. The type of surgical access did not change significantly, but lap-to-open conversion rate halved between the two study periods. Discharge diagnoses of appendicitis and diverticulitis reduced significantly, while bowel ischaemia and perianal ailments had a significant relative increase.ConclusionsOur audit demonstrates a significant overall reduction of emergency surgery admissions at the outbreak of the Covid-19 pandemic with a minimal change of the proportions of single presentations, diagnoses and treatments. These findings may open the door to new ways of managing surgical emergencies without engulfing the already busy hospitals.

A Single Institution’s Experience With Robotic Minor and Major Hepatectomy

Background Minimally invasive liver resection is gradually becoming the preferred technique to treat liver tumors due its salutary benefits when compared with traditional “open” method. While robotic technology improves surgeon dexterity to better perform complex operations, outcomes of robotic hepatectomy have not been adequately studied. We therefore describe our institutional experience with robotic minor and major hepatectomy. Materials and Methods We prospectively study all patients undergoing robotic hepatectomy from 2016 to 2020. Results A total of 220 patients underwent robotic hepatectomy. 138 (63%) were major hepatectomies while 82 (37%) were minor hepatectomies. Median age was 63 (62 ± 13) years, 118 (54%) were female. 168 patients had neoplastic disease and 52 patients had benign disease. Lesion size in patients who had undergone minor hepatectomy was 2 (3 ± 2.5) cm, compared to 5 (5 ± 3.0) cm in patients who undergone major hepatectomy ( P < .001). 97% of patients underwent R0 resections while none of the patients had R2 resection. Operative duration was 226 (260 ± 122.7) vs 282 (299 ± 118.7) minutes ( P ≤ .05); estimated blood loss was 100 (163 ± 259.2) vs 200 (251 ± 246.7) mL ( P ≤ .05) for minor and major hepatectomy, respectively. One patient had intraoperative bleeding requiring “open” conversion. Nine (4%) patients had experienced notable postoperative complications and 2 (1%) patients died postoperatively. Length of stay was 3 (5 ± 4.6) vs 4 (5 ± 2.8) days for minor vs major hepatectomy ( P = .84). Reoperation and readmission rate for minor vs major hepatectomy was 1% vs 3% ( P = .65) and 9% vs 10% ( P = .81), respectively. Discussion Robotic major hepatectomy is safe, feasible, and efficacious with excellent postoperative outcomes.

Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute cholecystitis

Background Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies. Methods This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013–2017, n = 17) and post-TG18 group (2018–2020, n = 27). Patients’ background demographics, surgical method, surgical results, and postoperative complications were compared. Results The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9–42] days vs. 8 [4–11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group. Conclusions For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.

Evolution and trends in the adoption of laparoscopic liver resection in Singapore: Analysis of 300 cases

ABSTRACT Introduction: The introduction of laparoscopic surgery has changed abdominal surgery. We evaluated the evolution and changing trends associated with adoption of laparoscopic liver resection (LLR) and the experience of a surgeon without prior LLR experience. Methods: A retrospective review of 310 patients who underwent LLR performed by a single surgeon from 2011 to 2020 was conducted. Exclusion criteria were patients who underwent laparoscopic liver surgeries such as excision biopsy, local ablation, drainage of abscesses and deroofing of liver cysts. There were 300 cases and the cohort was divided into 5 groups of 60 patients. Results: There were 288 patients who underwent a totally minimally invasive approach, including 28 robotic-assisted procedures. Open conversion occurred for 13 (4.3%) patients; the conversion rate decreased significantly from 10% in the initial period to 3.3% subsequently. There were 83 (27.7%) major resections and 131 (43.7%) resections were performed for tumours in the difficult posterosuperior location. There were 152 (50.7%) patients with previous abdominal surgery, including 52 (17.3%) repeat liver resections for recurrent tumours, and 60 patients had other concomitant operations. According to the Iwate criteria, 135 (44.7%) were graded as high/expert difficulty. Major morbidity (>grade 3a) occurred in 12 (4.0%) patients and there was no 30-day mortality. Comparison across the 5 patient groups demonstrated a significant trend towards older patients, higher American Society of Anesthesiologists (ASA) score, increasing frequency of LLR with previous abdominal surgery, increasing frequency of portal hypertension and huge tumours, decreasing blood loss and decreasing transfusion rate across the study period. Surgeon experience (≤60 cases) and Institut Mutualiste Montsouris (IMM) high grade resections were independent predictors of open conversion. Open conversion was associated with worse perioperative outcomes such as increased blood loss, transfusion rate, morbidity and length of stay. Conclusion: LLR can be safely adopted for resections of all difficulty grades, including major resections and for tumours located in the difficult posterosuperior segments, with a low open conversion rate. Keywords: Laparoscopic hepatectomy, laparoscopic liver resection, robotic hepatectomy, robotic liver resection, Singapore

IS THERE STILL A DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY? — AN EXPLORATIVE AND DESCRIPTIVE STUDY TO IDENTIFY RISK FACTORS AND TO ESTABLISH A SCORING SYSTEM FOR DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY.

Background: Gallstone disease is among the most common gastrointestinal illness requiring hospitalization. Laparoscopic cholecystectomy is now the preferred approach to its treatment. When performing laparoscopic cholecystectomy, the surgeon should have the low threshold for open conversion in case of difculty. The aim of the study was Pre-operative prediction of difcult laparoscopic cholecystectomy using clinical, ultrasonographic and intraoperative parameters. Methods:This study was done on 200 patients presenting with symptomatic cholelithiasis who underwent laparoscopic cholecystectomy. A prospective analysis of parameters including the patient demographics, laboratory values, radiologic data and intraoperative parameters was performed. Results: The factors which were considered a difculty parameter were males, age>60years, preoperative ERCP, rised amylase, sonographic features of contracted or distended gallbladder and pericholecystic collection. Intraoperative parameters were adhesions around gallbladder, contracted or distended gallbladder inamed gallbladder. Conclusions: The above mentioned factors must be adequately studied and the surgeon and the patient should be prepared for difcult laparoscopic cholecystectomy.

TP6.1.2 Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period

Aim Laparoscopic subtotal cholecystectomy is a safe strategy to avoid bile duct injury when a critical view of safety cannot be obtained. This technique may result in fewer open conversions and was introduced in our DGH in 2013. This study describes the change in practice at our centre following introduction of subtotal cholecystectomy. Method Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date; 2009-2012 (Group A) and 2013-2019 (Group B). These groups represent pre- (Group A) and post- (Group B) introduction of laparoscopic subtotal cholecystectomy. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic sub-total and lap-converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. Results There were 4248 cases; 1387 in Group A, and 2861 in Group B. The rate of open conversions was higher in Group A than Group B (4.7% vs. 2.8%, p = 0.003). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.3% vs. 92.8%, p = 0.013). In the subtotal group (n = 114, 3.9% of Group B); 14 (12.3%) patients had bile leak requiring ERCP, 6 (5.3%) underwent re-laparoscopy for inadequate biliary drainage, and median LOS was 2 days. Conclusion Laparoscopic subtotal cholecystectomy has proven to be a safe technique at our centre, reducing the rate of open conversion and length of stay, with a low rate of reintervention for bile leak.