INDOCYANINE GREEN ENHANCED LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE PATIENTS: DO WE NEED A REVISION OF THE SAFETY PARADIGMS?
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Introduction. Rapid developments in medical technology have allowed the incorporation of Indocyanine green (ICG) fluorescent cholangyography in the surgical technique armamentarium. The visualization of the biliary anatomy with augmented reality devices during surgery reduces complications and offer the perspective of challenging the safety paradigms which prohibited surgery in certain acute biliary conditions. Materials and methods. 43 consecutive patients were enrolled in a prospective interventional study and randomly divided into a cohort of 19 patients who had ICG injected prior to laparoscopic cholecystectomy and a cohort of 23 patients who received no fluorescent dye prior to surgery. In the ICG lot a Near Infrared Fluorescent System was used for the acquisition of fluorescent data in order to produce real time augmented reality imaging (ICG fluorescent cholangiography). The surgical technique and the indications for surgery were the same for the same in both cohorts of patients. Results and discussion. The cohort of patients receiving ICG had no complications and the mean operating time was 10 minutes less. The biliary anatomy was identified immediately in the ICG cohort with a specificity of 89.4% for the common bule duct and 73.6% for the cystic duct. In the non ICG cohort 21% of the CBDs and 43.4% of the cystic ducts were identified with difficulty during the procedure. Conclusion. We demonstrated in a small cohort of patients that early laparoscopic cholecystectomy is safe and can be performed quicker with the aid of fluorescent dyes. In order to challenge the safety paradigms around the early laparoscopic cholecystectomy a larger study is necessary.Keywords:
Indocyanine Green
Abstract A simple, easily reproducible technique of operative cholangiography is described. The technique has three advantages: (a) there is no need to divide or ligate the cystic duct; (b) it demonstrates the cystic duct anatomy clearly and is particularly useful in demonstrating stones in that duct thus eliminating the hazard of the retained stone in the cystic duct stump; (c) it is possible to eliminate the problem of false positives due to air bubbles. A consecutive series of 442 cholecystectomy patients is reviewed. The overall operative mortality was 1·6 per cent; no death could be attributed to operative cholangiography. Thirty-five of 324 patients (10·8 per cent) with gallstones and no history of jaundice were shown to have unexpected abnormalities in the common bile duct.
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Thirty-seven patients underwent cholecystectomy without intraoperative cholangiography. Patients were selected using clinical and investigatory parameters. One patient had a negative common bile duct exploration. During the follow-up period of 2½–3½ years, all patients remained symptomatically and sonologically free of stones.
Common Duct
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Objective To analyse the adva nt ages and disadvantages of minilap cholecystectomy and laparospic cholecystectomy .Methods We compared and analysed minilap cholecystectomy in 53 4 cases and laparoscopic cholecytectomy in 225 cases.Results Bo th minilap cholecystectomy and laparoscopic cholecystectomy had the features of less injury and early recovery,but minilap cholecystectomy also had the advantag es of flexibility of manipulating,fewer complications,lower expense,and generali zing easily.Conclusion Less injury operation will act a very im portant role in surgery of 21 centure.Minilap cholecystectomy can popularize eas ily in some primary hospitals.However innovation of equipment and skillful opera tion,laparoscpic cholecystectomy will possess bright tomorrow.
Open cholecystectomy
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A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients undergoing cholecystectomy is the clipless laparoscopic cholecystectomy is associated with higher risk of bile leak compared to conventional cholecystectomy? The search has been devised and 6 studies were deemed to be suitable to answer the question. The outcome assessed was the rate of bile leak in clipless cholecystectomy compared to conventional laparoscopic cholecystectomy. Authors found that the rates of bile leak in clipless laparoscopic cholecystectomy is comparable to conventional technique. Clipless cholecystectomy is feasible and safe.
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Open cholecystectomy
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Cholecystography
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A series of 1575 consecutive patients with cholelithiasis managed by cholecystectomy without operative cholangiography is presented. All operations were performed by one of our authors. Exploration of the bile ducts was performed in 185 (12%) patients. During the postoperative period there was evidence of retained calculi in three (1.6%) of the 185 patients. The incidence of remote calculi (those presenting at a time distant from cholecystectomy) was determined for patients undergoing cholecystectomy between 1963 and 1967. Follow up information was available on 258 (80%) of 321 patients. Clinical evidence of remote calculi was found in seven (2.7%) patients. The incidence of both retained and remote calculi was similar to that found in series where operative cholangiography was routine.
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A series of 78 patients with post-cholecystectomy biliary strictures have been examined. The majority (71%) did not have per-operative cholangiography at the time of initial cholecystectomy. Of the remainder, inadequate views were obtained in two patients and incomplete information was associated with subsequent common bile duct damage. In addition the study was performed after the common bile duct had been transected in a further two cases. The use of per-operative cholangiography in patients undergoing cholecystectomy is advocated, and the advantages and disadvantages of such an approach examined.
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• Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85 526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration. (Arch Surg. 1989;124:787-790)
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