Universal safe procedure of laparoscopic cholecystectomy standardized by exposing the inner layer of the subserosal layer (with video)

J Hepatobiliary Pancreat Sci

et al. 2017

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Background Generally, surgeons' perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. Methods A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200-499, 500-999, and ≥1,000). Results The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the "critical view of safety" technique, identification of Rouviere's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. Conclusions Even among experts, surgeons' perceptions during LC are workplacedependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence.

Section: Discussionmentioning

confidence: 99%

The “right” way is not always popular: comparison of surgeons’ perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan

J Hepatobiliary Pancreat Sci

et al. 2017

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“…In such instances, mobilization of the gallbladder off the cystic plate from the posterior aspect of the gallbladder neck might be important in securing safety during LC. Honda et al [36][37][38] proposed that the dissection of the gallbladder wall should always expose the "SS-Inner" layer to prevent BDI, based on anatomical and histological investigations. Although their concept was built upon a discussion between surgeons and pathologists, there are criticisms that the gallbladder serosa cannot be separated anatomically and hence the term "SS-Inner" layer is inappropriate.…”

Section: Discussionmentioning

confidence: 99%

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul‐de‐sac or the birth pangs of a new technical framework?

J Hepato Biliary Pancreat

et al. 2017

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Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a fivepoint scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first-and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/ clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/ scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

“…These reports alert surgeons to be extremely cautious whenever they cannot recognize surgical anatomy; nevertheless, none of these studies articulate whether the critical view of safety proposed by Strasberg et al can be obtained in such situations [26,27]. On the other hand, Honda et al recommended the exposure of the inner layer of the subserosal layer (SS-Inner layer) as a standardized technique to safely dissect the Calot's triangle area and achieve critical view of safety [28][29][30]. Moreover, they stated that this technique is useful to judge the level of inflammation (fibrotic change and/or scarring) in the gallbladder wall and to determine the surgical strategy (i.e.…”

Section: Discussionmentioning

confidence: 99%

An opportunity in difficulty: Japan-Korea-Taiwan expert Delphi consensus on surgical difficulty during laparoscopic cholecystectomy

J Hepatobiliary Pancreat Sci

et al. 2017

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Background We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty. Methods Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0-6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median AE 1 after stratification by workplace and LC experience level. Results Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. 'Diffuse scarring in the Calot's triangle area' in the 'Factors related to inflammation of the gallbladder' category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score. Conclusions A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.