Laparoscopic Cholecystectomy for Large/Giant Gallstones: Case Report and Brief Review of Literature

Gallstones disease are the most common biliary pathology. Its prevalence in Nepal is found to be 4.87%. Giant/large gallstones have a higher risk of complications and presents technical difficulties during laparoscopic cholecystectomy. Open cholecystectomy is preferred in most of the cases with giant gallstones. With the availability of experience laparoscopic surgeon and modern laparoscopic equipment, laparoscopic cholecystectomy is also feasible in large/giant gallstones. We report 2 cases, one large gallstone in 51 years old female and one giant gallstone in 39 years old female each of which were successfully managed laparoscopically with uneventful post-operative period.

Characterisation of trocar associated gas leaks during laparoscopic surgery

Background During laparoscopy, the abdominal cavity is insufflated with carbon dioxide (CO2) that could become contaminated with viruses and surgical smoke. Medical staff is potentially exposed when this gas leaks into the operating room through the instruments and past trocar valves. No detailed studies currently exist that have quantified these leakage pathways. Therefore, the goal of this study was to quantify the gas leakages through trocars and instruments, during minimally invasive procedures. Methods A model of the surgical environment was created, consisting of a rigid container with an interface for airtight clamping of laparoscopic equipment such as trocars and surgical instruments. The model was insufflated to 15 mm Hg using a pressure generator and a pneumotachograph measured the equipment gas leak. A protocol of several use cases was designed to simulate the motions and forces the surgeon exerts on the trocar during surgery. Results Twenty-three individual trocars and twenty-six laparoscopic instruments were measured for leakage under the different conditions of the protocol. Trocar leakages varied between 0 L/min and more than 30 L/min, the instruments revealed a range of leakages between 0 L/min and 5.5 L/min. The results showed that leakage performance varied widely between trocars and instruments and that the performance and location of the valves influenced trocar leakage. Conclusions We propose trocar redesigns to overcome specific causes of gas leaks. Moreover, an international testing standard for CO2 leakage for all new trocars and instruments is needed so surgical teams can avoid this potential health hazard when selecting new equipment.

Technical standardization of ICG near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy for duplex kidney in pediatric patients

Purpose This study aimed to standardize the operative technique of indocyanine green (ICG) near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy (LPN) and compare it with the standard technique. Methods In the last 4 years, we performed 22 LPN (14 right-sided, 8 left-sided) in children with non-functioning moiety of duplex kidney. Patients included 12 girls and 10 boys with a median age of 3.9 years (range 1–10). Patients were grouped according to the use of ICG-NIRF: G1 included 12 patients operated using ICG-NIRF and G2 included 10 patients receiving the standard technique. We standardized the technique of injection of ICG in three different steps. Results The median operative time was significantly lower in G1 [87 min (range 68–110)] compared with G2 [140 min (range 70–220)] (p = 0.001). One intra-operative complication occurred in G2. At post-operative ultrasound (US), the residual moiety was normal in all patients. An asymptomatic renal cyst related to the site of surgery was visualized at US in 8/22 (36%), with a significantly higher incidence in G2 (6/10, 60%) compared with G1 (2/12, 16.6%) (p = 0.001). Renogram demonstrated no loss of function of residual moiety. No allergic reactions to ICG occurred. Conclusion ICG-NIRF LPN is technically easier, quicker, and safer compared with the standard technique. The main advantages of using ICG-NIRF during LPN are the clear identification of normal ureter, vasculature of non-functioning pole, and demarcation line between the avascular and the perfused pole. The main limitation of ICG technology remains the need for specific laparoscopic equipment that is not always available.

Laparoscopic Cholecystectomy for Large/Giant Gallstones: Case Report and Brief Review of Literature.

Background Gallstones disease (GSD) is the most common biliary pathology. GSD is one of the common surgical problems in which lead people admit to the hospital in Nepal. Its prevalence is found to be 4.87%. The size of a gallstone is important, as giant/large gallstones have a higher risk of complications and present technical difficulties during laparoscopic cholecystectomy (LC). Open cholecystectomy is preferred in most cases with giant gallstones. With the availability of experienced laparoscopic surgeons and modern laparoscopic equipment LC is also feasible in large/giant gallstones. In this case report, we report 2 cases of one large and one giant gallstone each which were successfully done laparoscopically.Case Presentation Case 1 A 51 years old female presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty food with no significant past medical and surgical history.Ultrasound abdomen showed normal gallbladder with multiple gallstones, largest measuring approximately 4cms. She was planned for elective LC. The gallbladder was removed out after extension of the infra-umbilical incision. On the cut section, we found multiple gallstones with one large gallstone measuring 4*3.3*3 cm and weighted 23.2 gm. Her post-operative period was uneventful. Case 2 A 39 years old female, known case of hypertension under calcium channel blocker(CCB) and angiotensin receptor blocker(ARBs) presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty foods with non-significant surgical history. Ultrasound abdomen showed a normal gallbladder with a single large gallstone (approximately 4.7 cm). Elective LC was performed and the gallbladder was removed out after extension of infraumbilical incision. On the cut section, we found a single giant gallstone measuring 5* 3*2.8 cm and weighted 24.7 gm. Her post-operative period was uneventful.Conclusion Large/giant gallstones are associated with a high risk of complications and cholecystectomy is warranted in symptomatic and asymptomatic patients. Even for large/giant gallstones, LC appears to be the treatment of choice over open cholecystectomy and should be performed by an experienced laparoscopic surgeon, taking into consideration the possibility of conversion to open in case of inability to expose the anatomy and any intraoperative technical difficulties.

Near-infrared Intraoperative Imaging of Pelvic Autonomic Nerves: Clinical Trial

Background: The pelvic autonomic nerves control and regulate anorectal and urogenital function. The dysfunction of pelvic autonomic nerves lead to disorders of anorectum, bladder and male sex organs. Thus the intraoperative identification of pelvic autonomic nerves could be crucial in complications prevention and diseases treatment. Our clinical trial aims at estimating the effectiveness and validity of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves identification.Methods: Intraoperative fluorescence imaging using indocyanine green was performed in 10 patients and the feasibility was determined. From February 2019 to June 2019, the 10 patients undergoing laparoscopic colorectectomy was administrated 4.5 mg/Kg indocyanine green 24 hours before surgery. The near-infrared fluorescence imaging was conducted during surgery. A novel white light and near-infrared dual-channel laparoscopic equipment was applied. For each patient, signal background ratio values for pelvic autonomic nerves were recorded and analyzed.Results: We confirmed the best dose and timing of indocyanine green administration was 4.5 mg/Kg and 24 hours before surgery. Using the dual laparoscopic equipment, we could observe the splanchnic plexus, inferior mesenteric artery plexus, and sacral plexus successfully with a high signal background ratio value of 3.18 (standard deviation: 0.48). Conclusion: Pelvic autonomic nerves could be observed using indocyanine green fluorescence imaging during surgery. The novel method may replace the current visual identification method and become the standard clinical practice.

Near-Infrared Intraoperative Imaging of Pelvic Autonomic Nerves:Clinical Trial

Background: The pelvic autonomic nerves control and regulate anorectal and urogenital function. The dysfunction of pelvic autonomic nerves lead to disorders of anorectum, bladder and male sex organs. Thus the intraoperative identification of pelvic autonomic nerves could be crucial in complications prevention and diseases treatment. Our clinical trial aims at estimating the effectiveness and validity of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves identification.Methods: Intraoperative fluorescence imaging using indocyanine green was performed in 10 patients and the feasibility was determined. From February 2019 to June 2019, the 10 patients undergoing laparoscopic colorectectomy was administrated 4.5 mg/Kg indocyanine green 24 hours before surgery. The near-infrared fluorescence imaging was conducted during surgery. A novel white light and near-infrared dual-channel laparoscopic equipment was applied. For each patient, signal background ratio values for pelvic autonomic nerves were recorded and analyzed.Results: We confirmed the best dose and timing of indocyanine green administration was 4.5 mg/Kg and 24 hours before surgery. Using the dual laparoscopic equipment, we could observe the splanchnic plexus, inferior mesenteric artery plexus, and sacral plexus successfully with a high signal background ratio value of 3.18 (standard deviation: 0.48). Conclusion: Pelvic autonomic nerves could be observed using indocyanine green fluorescence imaging during surgery. The novel method may replace the current visual identification method and become the standard clinical practice.

Predictors of Poor Postoperative Outcomes in Pediatric Surgery Patients in Rural Ghana

Background/Purpose Perioperative complications cause significant pediatric morbidity and mortality in low- and lower middle -income countries. This study investigates factors associated with prolonged length of stay, 90-day readmission and in-hospital mortality among pediatric patients at Eastern Regional Hospital (ERH) in Ghana. Methods This is a retrospective review of perioperative morbidity and mortality in children < 18 years at ERH in Koforidua, Ghana. All pediatric surgeries performed between January 2015 and December 2017 were included in this study. Univariate analysis was performed using Pearson’s chi-square tests or Fisher’s exact tests. Variables that were significant on univariate analysis were included in multivariable logistic regression models adjusted for age and gender. Results We analyzed 468 patients < 18 years of age with a median length of stay (LOS) of 3 days. The 90-day readmission and in-hospital mortality rates were 138 and 17 per 1000 patients, respectively. The most common procedures were herniorrhaphy (19 %) and appendectomy (15 %). Gastrointestinal surgery, surgical trauma, surgical infection and lack of insurance were significantly associated with prolonged LOS. Young age and female gender were significantly associated with in-hospital mortality. Malaria was significantly associated with 90-day readmission. Conclusions Malaria infection is a significant risk factor for readmission, which should be investigated and treated in pediatric surgical patients in rural Ghana. Ensuring that all patients have insurance may result in shorter hospital stays. Provision of laparoscopic equipment may reduce hospital stays for patients undergoing gastrointestinal surgery. Expansion of the surgical work force, particularly pediatric surgeons, could improve perioperative survival in the very young population. Level of Evidence Retrospective comparative study.

Predictors of Poor Postoperative Outcomes in Pediatric Surgery Patients in Rural Ghana

Background/Purpose: Perioperative complications cause significant pediatric morbidity and mortality in low- and lower middle -income countries. This study investigates factors associated with prolonged length of stay, 90-day readmission and in-hospital mortality among pediatric patients at Eastern Regional Hospital (ERH) in Ghana. Methods: This is a retrospective review of perioperative morbidity and mortality in children <18 years at ERH in Koforidua, Ghana. All pediatric surgeries performed between January 2015 and December 2017 were included in this study. Univariate analysis was performed using Pearson’s chi-square tests or Fisher’s exact tests. Variables that were significant on univariate analysis were included in multivariable logistic regression models adjusted for age and gender.Results: We analyzed 468 patients <18 years of age with a median length of stay (LOS) of 3 days. The 90-day readmission and in-hospital mortality rates were 138 and 17 per 1000 patients, respectively. The most common procedures were herniorrhaphy (19%) and appendectomy (15%). Gastrointestinal surgery, surgical trauma, surgical infection and lack of insurance were significantly associated with prolonged LOS. Young age and female gender were significantly associated with in-hospital mortality. Malaria was significantly associated with 90-day readmission. Conclusions: Malaria infection is a significant risk factor for readmission, which should be investigated and treated in pediatric surgical patients in rural Ghana. Ensuring that all patients have insurance may result in shorter hospital stays. Provision of laparoscopic equipment may reduce hospital stays for patients undergoing gastrointestinal surgery. Expansion of the surgical work force, particularly pediatric surgeons, could improve perioperative survival in the very young population.

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy

Introduction: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. Methods: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship- and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. Results: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). Conclusions: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Predictors of Poor Postoperative Outcomes in Pediatric Surgery Patients in Rural Ghana

Background/Purpose: Perioperative complications cause significant pediatric morbidity and mortality in low- and lower middle -income countries. This study investigates factors associated with prolonged length of stay, 90-day readmission and in-hospital mortality among pediatric patients at Eastern Regional Hospital (ERH) in Ghana. Methods: This is a retrospective review of perioperative morbidity and mortality in children <18 years at ERH in Koforidua, Ghana. All pediatric surgeries performed between January 2015 and December 2017 were included in this study . Univariate analysis was performed using Pearson’s chi-square tests or Fisher’s exact tests. Variables that were significant on univariate analysis were included in multivariable logistic regression models adjusted for age and gender.Results: We analyzed 468 patients <18 years of age with a median length of stay (LOS) of 3 days. The 90-day readmission and in-hospital mortality rates were 138 and 17 per 1000 patients, respectively. The most common procedures were herniorrhaphy (19%) and appendectomy (15%). Gastrointestinal surgery, surgical trauma, surgical infection and lack of insurance were significantly associated with prolonged LOS. Young age and female gender were significantly associated with in-hospital mortality. Malaria was significantly associated with 90-day readmission. Conclusions: Malaria infection is a significant risk factor for readmission, which should be investigated and treated in pediatric surgical patients in rural Ghana. Ensuring that all patients have insurance may result in shorter hospital stays. Provision of laparoscopic equipment may reduce hospital stays for patients undergoing gastrointestinal surgery. Expansion of the surgical work force, particularly pediatric surgeons, could improve perioperative survival in the very young population.