Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic ...cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification – the “inflection point”; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy – and instead to “bail‐out”. This “inflection point” is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail‐out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.
Highlight
Strasberg describes the three conceptual goals of cholecystectomy: (1) obtaining secure anatomical identification of key structures, (2) making the decision not to perform total cholecystectomy when conditions are too dangerous to obtain secure identification – the “inflection point” and (3) finishing the operation safely when secure anatomical identification is not possible.
The Brisbane 2000 Nomenclature of Hepatic Anatomy and Resections was created to standardize terminology in an area, which previously was characterized by redundant and confusing terms. The purpose of ...this study was to evaluate the use and dissemination of the nomenclature 10 years after its introduction.
Two strategies were used to evaluate implementation of the terminology. The first depended on an examination of terms used to describe the anatomy and resection of one half of the liver over the 20-year period from 1990 to 2009. The second approach evaluated the use of the terms "section," "sectionectomy," and "trisectionectomy," which, in reference to the liver, are unique to the Brisbane 2000 Nomenclature.
The use of the Brisbane 2000 terms "right and left hemihepatectomy/hepatectomy" increased dramatically versus the use of the discarded terms "right and left hepatic lobectomy" after the Nomenclature was introduced in 2000. This was especially true in the Americas and Asia where the terms were used in less than 50% of papers from 1990 to 1999 but reached 80% utilization by 2006. Likewise, use of the terms "section," "sectionectomy," and "trisectionectomy" increased sharply especially in between 2006 and 2009.
The Brisbane terminology is being adopted worldwide but its adoption is still incomplete.
Less than complete cholecystectomy has been advocated for difficult operative conditions for more than 100 years. These operations are called partial or subtotal cholecystectomy, but the terms are ...poorly defined and do not stipulate whether a remnant gallbladder is created. This article briefly reviews the history and development of the procedures and introduces new terms to clarify the field. The term partial is discarded, and subtotal cholecystectomies are divided into “fenestrating” and “reconstituting” types. Subtotal reconstituting cholecystectomy closes off the lower end of the gallbladder, reducing the incidence of postoperative fistula, but creates a remnant gallbladder, which may result in recurrence of symptomatic cholecystolithiasis. Subtotal fenestrating cholecystectomy does not occlude the gallbladder, but may suture the cystic duct internally. It has a higher incidence of postoperative biliary fistula, but does not appear to be associated with recurrent cholecystolithiasis. Laparoscopic subtotal cholecystectomy has advantages but may require advanced laparoscopic skills.
Background
Observational studies have identified risk factors for conversion from laparoscopic to open cholecystectomy in acute cholecystitis. The aim of this study is to evaluate the reliability of ...these predictors and to identify sources of heterogeneity in the studies.
Methods
OVID was searched for papers published from 1995 to 2016. Studies with more than 100 patients were included. Risk factors for conversion were ed and categorized by statistical significance.
Results
Eleven studies were evaluated. Inflammation with difficulty in anatomic identification was the most common reason of conversion. Because of heterogeneity among studies a quantitative approach was not possible. Therefore, qualitative analysis using a heat map was performed along with investigation into sources of heterogeneity with the aim of creating a framework for future quantitative studies. Age, maleness, and white blood cell count were most commonly identified predictors of conversion. Sources of heterogeneity were criteria for diagnosis of acute cholecystitis, selection of patients for laparoscopic cholecystectomy, selection of variables and variations in their thresholds.
Conclusions
In acute cholecystitis, inflammation is the most common reason for conversion. Age, maleness and white blood cell count are common predictors of conversion. Large scale prospective studies with minimal heterogeneity are needed to establish validity of these and other predictors.
Highlight
Risk factors for conversion to open cholecystectomy in acute cholecystitis were evaluated in published observational studies. Heterogeneity in criteria for diagnosis, selection of patients, selection of variables, and variations in thresholds was observed. This limited conclusions. Large scale prospective studies with limited and measurable heterogeneity are needed for predictive models.
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