IRCAD recommendation on safe laparoscopic cholecystectomy

Abstract

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

Navigation with laparoscopic ultrasound during fundus-first laparoscopic cholecystectomy-a single-centre retrospective case control study

“…The reason for conversion in the FF + LUS group was the laparoscopically undissectable brous tissue which disabled safe performance of the procedure (3 patients) whereas in the FF group these were unclear anatomy (2 patients), undissectable brous tissue (2 patients) and bleeding (1 patient). de nes three major causes of BDI: (1) technique associated with the surgeon's experience and performance, (2) pathology related to the extent of in ammation and (3) presence of anatomical variations whereas the most common reason of BDI is the misidenti cation of the common hepatic/bile duct instead of the cystic duct [10,13,14]. The safest way to complete cholecystectomy is to obtain CVS but the problems may arise in the case of in ammation in the region of Calot's triangle [10,13,14].…”

“…de nes three major causes of BDI: (1) technique associated with the surgeon's experience and performance, (2) pathology related to the extent of in ammation and (3) presence of anatomical variations whereas the most common reason of BDI is the misidenti cation of the common hepatic/bile duct instead of the cystic duct [10,13,14]. The safest way to complete cholecystectomy is to obtain CVS but the problems may arise in the case of in ammation in the region of Calot's triangle [10,13,14]. CVS is not a dissection technique, but rather a technique of identi cation similar to the safety measures during hunting or ying [13,15].…”

“…FF LC is an alternative technique when there is a severe in ammation or brosis in the triangle of Calot [10].…”

“…The gallbladder remnant is either left open in fenestrating variant or oversewn in the second reconstituting variant [2]. The latter may expose the patient to the recurrence of gallstone disease due to the closed remnant of the gallbladder (with the rate of 2.2%) but the open variant is associated with higher bile leaks (10.6%) [10,13,14,19].The key to successful subtotal cholecystectomy is to remove as much as possible gallbladder wall but the surgeon is sometimes not sure where to stop and at which level close the remnant of the gallbladder. The same as with the FF technique LUS de nes very precisely the safe plane of dissection without the risk of BDI and VBI.…”

Enabling precision digestive surgery with fluorescence imaging

“…As an example, NIR fluorescence cholangiography (NIR-C) seems an accurate method to identify biliary structures and possibly to prevent bile duct injuries (1,8), with the advantages of being real-time, low-cost and radiation-free. NIR-C is based on the injection of a bile-excreted fluorophore [indocyanine green (ICG)], which becomes fluorescent upon excitation by a NIR light.…”