P-BN17 Laparoscopic subtotal cholecystectomy is a safe and effective treatment for gallstone disease

Background Laparoscopic cholecystectomy is the gold standard treatment of gallstones in fit patients with symptomatic gallbladder disease. If the critical view of safety cannot be achieved intra-operatively, there are few options, one of which is laparoscopic subtotal cholecystectomy. This study aims to ascertain the outcomes of subtotal cholecystectomy. Methods Retrospective review of all patients who underwent laparoscopic subtotal cholecystectomy by a single surgeon over a 5 year period. Results 37 consecutive patients who underwent subtotal cholecystectomy were included in this study; seventeen of which were males (49%); the median age was 69, and 18 were emergencies (49%).The most common reasons for conversion to laparoscopic subtotal cholecystectomy were adhesions (57%) and fibrotic Calot’s triangle (22%). One patient required ERCP and biliary stenting for ongoing bile leak and another returned to theatre for post operative bleeding during index admission. 6 patients (16%) required further hospital admissions for gallstone disease (1 for biliary colic, two for cholecystitis and three for CBD stones). 3 patients required ERCP. None required further gallbladder surgery. Conclusions Laparoscopic subtotal cholecystectomy is a safe and effective alternative to total cholecystectomy when the critical view of safety cannot be achieved. In our experience, only a small proportion of patients have recurrent biliary problems.

O-BN02 Laparoscopic subtotal cholecystectomy for difficult gallbladders: A lifesaving bailout or an incomplete operation? A systematic review

Background Cholecystectomy is one of the commonest abdominal operations performed worldwide. Sometimes, the operation can be technically difficult due to dense adhesions in Calot’s triangle. Conversion to open surgery or subtotal cholecystectomy have been described to deal with these situations. A recent systematic review and meta-analysis on STC suggested high perioperative morbidity associated with STC. These findings are at odds with a previous systematic review and meta-analysis on the topic which concluded that morbidity rates for STC were comparable to those reported for total cholecystectomy. However, both these reviews included patients undergoing Open Subtotal Cholecystectomy (OSTC). This makes it difficult for us to understand the outcomes of LSTC as surgeons are not faced with the choice of converting to open surgery to perform a subtotal cholecystectomy. The choice they face is whether they should perform a LSTC or convert to open surgery to perform a total cholecystectomy. It is, therefore, important to establish the outcomes of LSTC alone (without including patients who underwent OSTC). This is all the more important during COVID-19 pandemic when the complexity of gall stone disease appears to have worsened. There is thus an enhanced need to understand technical nuances and outcomes of LSTC alone. Methods Search strategy: We searched PUBMED (Medline), Google Scholar, and Embase for all relevant English language articles describing experience with LSTC in adult human population (≥18 years) anywhere in the world using key-words like “subtotal cholecystectomy”, “gallbladder resection”, “gallbladder excision”, “gallbladder removal”, “partial”, “incomplete”, “insufficient”, “deroofing”, and “near-total”. Case reports, articles only published as conference abstracts, case series with <5 cases, and reviews were excluded. Only English-language studies were included. Participants: All studies with 5 or more cases, describing any experience with an adult cohort (≥18 years) of patients undergoing STC while attempting a Laparoscopic Cholecystectomy were included. Studies on patients who underwent preoperative cholecystostomy were excluded. Studies that had LSTC as part of another surgery were also excluded as we wanted to understand the morbidity and mortality of LSTC alone. Studies on patients who underwent OSTC (Open from start) were excluded as were those where the LSTC cohort was merged with the OSTC cohort and outcomes of LSTC were not separately reported. Study outcome: Primary outcome measure was early (≤30 days) morbidity and mortality. Secondary outcome measures were bile duct injury, bile leak rates, conversion to open surgery rates, duration of hospital stay, and late (>30 days) morbidity. Results 45 studies were identified, with a total of 2166 patients. Mean age was 55 +/- 15 years with 51% females; 53% (n = 390) were elective procedures. The conversion rate was 6.2% (n = 135). Most common indication was acute cholecystitis (n = 763). Different techniques were used with the majority having a closed cystic duct/gallbladder stump (n = 1188, 71%). The most common closure technique was intracorporeal suturing (53%) followed by endoloop closure. There were a total of four, 30-day mortality [1] in this review. Early morbidity (≤30 days) included bile duct injury (0.23%), bile leak rates (18%), intra-abdominal collection (4%). Reoperation was reported in 23 patients (1%), most commonly for unresolving intra-abdominal collections and failed ERCP to control bile leak. Long term follow-up was reported in 30 studies with a median follow up period of 22 months. Late morbidity included incisional hernias (6%), CBD stones (2%), and symptomatic gallstones in 4% (n = 41) with 2% (n = 22) requiring completion of cholecystectomy. Conclusions Laparoscopic subtotal cholecystectomy is an acceptable alternative in patients with a “difficult” Calot’s triangle. However, this has to be taken seriously as it is associated with a high early and late morbidity and mortality.

P-BN54 The outcomes after a Laparoscopic subtotal cholecystectomy

Background Laparoscopic subtotal cholecystectomy (LSC) is a recognised option when the “critical view” cannot be safely delineated. It carries a high morbidity rate as there are increased frequencies of a bile leak occurring however reducing the risk of bile duct injury. LSC can be further divided into fenestrating or reconstituting cholecystectomy, the later entails closing the remnant. The literature state reconstituting cholecystectomy reduced rate of bile leak. We reviewed our cases to analyse the complication rates of LSC and there outcomes. Methods A retrospective review of patients who underwent a laparoscopic subtotal cholecystectomy (LSC) using electronic records between January 2015 to March 2021. A total of 160 patients, with a mean age of 65, 51% male and 49% female. Results 76% of LSC were performed as an emergency. Mean operation length was 96min and the mean blood loss 92ml. Complications occurred in 50% of patients. Post operatively 22% underwent an ERCP and the re-operation rate was 9%. The mean length of stay was 8 days. Conclusions Based on our results LSC carry a high rate of bile leak with the majority requiring intervention in the form of ERCP or laparoscopy and wash out. A reconstituting cholecystectomy, closing with an endoloop of suture seems to slightly reduce the rate of bile leak. LSC are only performed when managing a difficult gallbladder with a dense/ inflamed Calot's triangle. There were no mortalities associated with a LSC.

Conversion of laparoscopic cholecystectomy to open cholecystectomy in a single center

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversions to open cholecystectomy are still inevitable in certain cases. Knowledge about the rate and underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decide to review the rate and causes of conversion of our LC series. This study included 320 consecutive laparoscopic cholecystectomies from January 2017 to December 2019 at Community Based Medical College Hospital Bangladesh, Mymensingh. All patients had surgery performed by same surgeon. Conversion to open cholecystectomy required in 15 (4.6%) patients. Out of 15 cases, the highest number of patients 10(66.6%) were in age group 50 to 59 years with a mean age of 60.1 years and standard deviation (SD) of 9.8 years. Of them 9 (60%) were male. The most common reasons for conversion of them were severe adhesions at calot's triangle 6 (40%) and acutely inflamed gallbladder 5 (33.3%), bleeding 2 (13%). No surgical procedures are complication free. The most common complication was superficial wound infection 8(2.5%). Delayed complications seen in our series is port site incisional hernia 2 (0.62%). Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. LC is the preferred method even in difficult cases. This study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands, the surgeons should keep a low threshold for conversion to open surgery. CBMJ 2020 July: Vol. 09 No. 02 P: 14-18

Bile Duct Injury in Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy is commonly performed surgical procedure for symptomatic gall stone disease due to its better cosmetic results and shorter hospital stay; however, its safety in some cases is still questionable5. Methods: A retrospective, observational study was done in surgical unit 1, Sir Ganga Ram hospital, Lahore, from January 2017 to December 2019. Results: There were 209 cases whose surgical notes, hospital record and follow up notes were studied. Among these, 21 cases were converted to open. There was no injury of bile duct in any case. Conclusion: Experience of surgeon, careful dissection at calot’s triangle, use of critical view of safety and timely decision for conversion to open were factors participating insafe surgery. Keywords: Laparoscopic Cholecystectomy, Bile duct injury, critical view of safety

62 Evaluation of Laparoscopic Cholecystectomy with the help of AI-Video Analytics Platform

Aim This report aims to evaluate the use of an AI video analytics platform in laparoscopic cholecystectomy (LC) based on the achievement of the critical view of safety (CVS) and to assess its ability to correctly comment on CVS. Method Touch surgery video platform, an AI-video based analytic tool, was screened for laparoscopic cholecystectomy in our institute and analysed from April 2019 till October 2020. Data collected by the AI included identification of the critical view of safety and time needed to achieve CVS. A reviewer graded the LC according to Nasser grading and evaluated the ability of AI to identify the CVS. Results 66 LC were included from our video database. CVS was achieved in only 56% (37/66) in all LC videos included. Mean time spent to attend CVS from start of dissection of Calot’s triangle 16.8 (±13.6) mins. 26 (39.4%) LCs were Nasser grade 2 and 20 (30.3%) each were grade 1 and grade 3. There was no significant difference between number of CVS obtained between all grades. Time spent to achieve CVS from dissecting Calot’s triangle were the longest in grade 3 LCs (28.4±17.4 mins) with significant difference between all 3 grades. Finally, the platform correctly commented on CVS in 92.4% of the all LC videos. Conclusions AI video analytics can provide a useful tool to assess laparoscopic cholecystectomies and the critical view of safety. Additionally, more studies should explore the use of the platfrom and integrate the results with the clinical outcomes.

Anatomical Study of Variations of Cystic Artery and Contents of Calot’s Triangle in South Kerala - A Cross Sectional Study

BACKGROUND Cystic artery originates from right hepatic artery which is a branch of hepatic artery proper of coeliac trunk from abdominal aorta. Variations in the origin and course of cystic artery were observed in this study. Contents of Calot’s triangle were also studied. Knowledge of normal anatomy, variations of the biliary apparatus and the arterial supply to the gallbladder is important for surgeon. METHODS Descriptive cross-sectional study was done from April 2008 to January 2010 in 180 adult specimens and 50 foetal specimens in the Departments of Anatomy, Forensic Medicine and Pathology in Government Medical College, Thiruvananthapuram. The abdominal wall was incised and hepatobiliary region was identified and dissected. The gallbladder and coeliac trunk were identified. Cystic artery and Calot’s triangle were studied. RESULTS More than 90 percent of the cystic artery originates from the right hepatic artery in both sexes. Cystic artery originated from left hepatic artery in 4 cases, common hepatic artery in 5 cases and from middle hepatic artery in 1 case. The cystic artery within Calot’s triangle was observed in 41 %. Right hepatic artery was content in 29.9 %. Both the arteries were content in 19 %. Cystic artery and accessory hepatic duct were content of Calot’s triangle in 2.2 %. Double cystic artery was content of the triangle in 1 cadaver. Artery or duct was seen outside the Calot’s triangle in 16 cadavers. CONCLUSIONS It is important for surgeons to know the variations of cystic artery and Calot’s triangle during surgical interventions of the hepato biliary region. “Cystic artery syndrome” is a condition where cystic artery is seen winding around cystic duct although it originates from right hepatic artery. Knowledge of these variations is important for surgeons and helps in better surgical outcome. KEYWORDS Cystic Artery, Calot’s Triangle, Right Hepatic, Gall Bladder, Coeliac Trunk

Intraoperative strategies to overcome difficulties in laparoscopic cholecystectomy for chronic calculous cholecystitis

Background: Surgery in chronic cholecystitis is very challenging because of inability to hold the gall bladder, dense adhesions, frozen Calot’s triangle and difficulty in applying clips. Precise and meticulous dissection is required to establish critical view of safety. There is no consensus among surgeons about appropriate intraoperative steps in difficult gall bladder (GB) surgery. The authors aim to present various intraoperative difficulties and strategies to overcome them. Methods: A prospective study of 81 patients of chronic cholecystitis was done in our institution. They were divided in two groups. Group A in which surgery could be done easily. Group B in which surgery was difficult and different intraoperative strategies were applied to overcome them. Results: Total 42 patients were included in group A and 39 patients in group B. Various difficulties encountered while performing laparoscopic cholecystectomy in group B were adhesions (53.8 %), inability to grasp the fundus of GB (15.3%), frozen Calot’s triangle (15.3%), inability to grasp the Hartmann’s pouch (12.8%) and cystic duct edema (2.5%). Conclusions: Intraoperative technique of identification of Rouviere′s sulcus first, followed by high peritoneal incision on the GB body. Subsequently blunt dissection of Calot’s triangle using gauze piece and hydro dissection by suction irrigation canula ventral to the sulcus. It created a retro gall bladder tunnel safely. It established the critical view of safety in all our cases.

Successful treatment of emphysematous cholecystitis by laparoscopic surgery

Emphysematous cholecystitis (EC) is a severe and rare variant of acute cholecystitis characterized by ischemia of the gallbladder wall with gas-forming bacterial proliferation. Open cholecystectomy is traditionally the gold standard approach to treatment due to difficulty in isolating Calot’s triangle in the setting of intense inflammation. We present a case of EC successfully and safely treated by laparoscopic surgery.