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CC BY 4.0 · Surg J (N Y) 2021; 07(01): e35-e40
DOI: 10.1055/s-0040-1721432
Original Article

Novel Use of Intraoperative Fluoroscopy in an Era of ICG for Complex Laparoscopic Cholecystectomy

Jignesh A. Gandhi 
1   Department of GI and Laparoscopic Surgery, Global Hospital, Mumbai, Maharashtra, India
,
Pravin H. Shinde 
2   Department of General Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
,
Sadashiv N. Chaudhari
2   Department of General Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
,
Amay M. Banker 
2   Department of General Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
› Author Affiliations Funding All authors declare that there were no sources of funding for this study.
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Abstract

Background Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD.

Methods A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct.

Results The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment.

Conclusion This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.

Keywords

fluoroscopy - gall bladder - CBD stenting - laparoscopic cholecystectomy - gangrenous cholecystitis

Ethics Approval

This research study was conducted retrospectively from data obtained for clinical purposes. Ethical approval was granted by the Institutional Ethics Committee.


Availability of Data and Material

All patient records were obtained from the medical records department of our hospital.


Code Availability

Not applicable.


Consent to Participate and Consent for Publication

Owing to the retrospective nature of the study and since anonymity of the patient data was ensured, a waiver of consent was granted by our Institutional Ethics Committee.


Authors' Contributions

All authors contributed to the study equally. J.G. contributed toward study conception, study design, and writing of manuscript. P.S. contributed toward study design and writing of manuscript. S.C. did the study design. A.B. contributed toward data collection, statistical analysis, and writing of manuscript. All authors read and approved the final manuscript.




Publication History

Received: 14 August 2020

Accepted: 14 October 2020

Article published online:
28 February 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Ambe P, Esfahani BJ, Tasci I, Christ H, Köhler L. Is laparoscopic cholecystectomy more challenging in male patients?. Surg Endosc 2011; 25 (07) 2236-2240
    CrossrefPubMedGoogle Scholar
  • 2 Okamoto K, Suzuki K, Takada T. et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci 2018; 25 (01) 55-72
    CrossrefPubMedGoogle Scholar
  • 3 Ambe PC, Plambeck J, Fernandez-Jesberg V, Zarras K. The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients. Patient Saf Surg 2019; 13 (01) 2
    CrossrefPubMedGoogle Scholar
  • 4 Ambe PC, Jansen S, Macher-Heidrich S, Zirngibl H. Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany. Surg Endosc 2016; 30 (12) 5319-5324
    CrossrefPubMedGoogle Scholar
  • 5 Jansen S, Doerner J, Macher-Heidrich S, Zirngibl H, Ambe PC. S J. Outcome of acute perforated cholecystitis: a register study of over 5000 cases from a quality control database in Germany. Surg Endosc 2017; 31 (04) 1896-1900
    CrossrefPubMedGoogle Scholar
  • 6 Walsh RM, Henderson JM, Vogt DP, Brown N. Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies. Surgery 2007; 142 (04) 450-456 , discussion 456–457
    CrossrefPubMedGoogle Scholar
  • 7 Booij KAC, de Reuver PR, van Dieren S. et al. Long-term impact of bile duct injury on morbidity, mortality, quality of life, and work related limitations. Ann Surg 2018; 268 (01) 143-150
    CrossrefPubMedGoogle Scholar
  • 8 Schreuder AM, Busch OR, Besselink MG. et al. Long-term impact of iatrogenic bile duct injury. Dig Surg 2020; 37: 10-21
    CrossrefPubMedGoogle Scholar
  • 9 Machi J, Johnson JO, Deziel DJ. et al. The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study. Surgical Endoscopy 2008; 23 (02) 384-388
    CrossrefPubMedGoogle Scholar
  • 10 Ankersmit M, van Dam DA, van Rijswijk AS, van den Heuvel B, Tuynman JB, Meijerink WJHJ. Fluorescent imaging with indocyanine green during laparoscopic cholecystectomy in patients at increased risk of bile duct injury. Surg Innov 2017; 24 (03) 245-252
    CrossrefPubMedGoogle Scholar
  • 11 Hiwatashi K, Okumura H, Setoyama T. et al. Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: a retrospective study. Medicine (Baltimore) 2018; 97 (30) e11654
    CrossrefPubMedGoogle Scholar
  • 12 Yokoe M, Hata J, Takada T. et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25 (01) 41-54
    CrossrefPubMedGoogle Scholar
  • 13 Gomi H, Solomkin JS, Schlossberg D. et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018; 25 (01) 3-16
    CrossrefPubMedGoogle Scholar
  • 14 Srinivasan D, Than KD, Wang AC. et al. Radiation safety and spine surgery: Systematic review of exposure limits and methods to minimize radiation exposure. World Neurosurg 2014; (82) 1337-1343
    CrossrefPubMedGoogle Scholar
  • 15 Maekawa S, Nomura R, Murase T, Ann Y, Oeholm M, Harada M. Endoscopic gallbladder stenting for acute cholecystitis: a retrospective study of 46 elderly patients aged 65 years or older. BMC Gastroenterol 2013; 13: 65
    CrossrefPubMedGoogle Scholar
  • 16 Navez B, Mutter D, Russier Y. et al. Safety of laparoscopic approach for acute cholecystitis: retrospective study of 609 cases. World J Surg 2001; 25 (10) 1352-1356
    CrossrefPubMedGoogle Scholar
  • 17 Berci G, Sackier JM, Paz-Partlow M. Routine or selected intraoperative cholangiography during laparoscopic cholecystectomy?. Am J Surg 1991; 161 (03) 355-360
    CrossrefPubMedGoogle Scholar
  • 18 Thurley PD, Dhingsa R. Laparoscopic cholecystectomy: postoperative imaging. Am J Roentgenol 2012; 191 (03) 794-801
    CrossrefPubMedGoogle Scholar
  • 19 Dolan JP, Diggs BS, Sheppard BC, Hunter JG. Ten-year trend in the national volume of bile duct injuries requiring operative repair. Surg Endosc Other Interventional Tech 2005; 19 (07) 967-973
    CrossrefPubMedGoogle Scholar
  • 20 Giger U, Ouaissi M, Schmitz S-FH, Krähenbühl S, Krähenbühl L. Bile duct injury and use of cholangiography during laparoscopic cholecystectomy. Br J Surg 2011; 98 (03) 391-396
    CrossrefPubMedGoogle Scholar
  • 21 Khan OA, Balaji S, Branagan G, Bennett DH, Davies N. Randomized clinical trial of routine on-table cholangiography during laparoscopic cholecystectomy. Br J Surg 2011; 98 (03) 362-367
    CrossrefPubMedGoogle Scholar
  • 22 Nuzzo G, Giuliante F, Giovannini I. et al. Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 2005; 140 (10) 986-992
    CrossrefPubMedGoogle Scholar
  • 23 Tantia O, Jain M, Khanna S, Sen B. Iatrogenic biliary injury: 13,305 cholecystectomies experienced by a single surgical team over more than 13 years. Surg Endosc 2008; 22 (04) 1077-1086
    CrossrefPubMedGoogle Scholar
  • 24 Törnqvist B, Waage A, Zheng Z, Ye W, Nilsson M. Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy, a population-based case-control study. World J Surg 2016; 40 (05) 1060-1067
    CrossrefPubMedGoogle Scholar
  • 25 Kum C-K, Eypasch E, Lefering R, Paul A, Neugebauer E, Troidl H. Laparoscopic cholecystectomy for acute cholecystitis: is it really safe?. World J Surg 1996; 20 (01) 43-49
    CrossrefPubMedGoogle Scholar
  • 26 Sicklick JK, Camp MS, Lillemoe KD. et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg 2005; 241 (05) 786-792 , discussion 793–795
    CrossrefPubMedGoogle Scholar
  • 27 Ismael HN, Cox S, Cooper A, Narula N, Aloia T. The morbidity and mortality of hepaticojejunostomies for complex bile duct injuries: a multi-institutional analysis of risk factors and outcomes using NSQIP. HPB (Oxford) 2017; 19 (04) 352-358
    CrossrefPubMedGoogle Scholar
  • 28 Bickel A, Rappaport A, Kanievski V. et al. Laparoscopic management of acute cholecystitis. Surg Endosc 2014; 10 (11) 1045-1049
    CrossrefPubMedGoogle Scholar
  • 29 Lujan JA, Parrilla P, Robles R, Marin P, Torralba JA, Garcia-Ayllon J. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study. Arch Surg 1998; 133 (02) 173-175
    CrossrefPubMedGoogle Scholar
  • 30 Calhoun PC, Adams LH, Adams MR. Comparison of laparoscopic and minilap cholecystectomy for acute cholecystitis. Surg Endosc 1994; 8 (11) 1301-1304
    CrossrefPubMedGoogle Scholar
  • 31 Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998; 351 (9099): 321-325
    CrossrefPubMedGoogle Scholar
  • 32 Wakabayashi G, Iwashita Y, Hibi T. et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25 (01) 73-86
    CrossrefPubMedGoogle Scholar
  • 33 Kumar A, Kumar U, Munghate A, Bawa A. Role of routine intraoperative cholangiography during laparoscopic cholecystectomy. Surg Endosc 2015; 29 (09) 2837-2840
    CrossrefPubMedGoogle Scholar
  • 34 Kochar B, Akshintala VS, Afghani E. et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015; 81 (01) 143-149.e9
    CrossrefPubMedGoogle Scholar
  • 35 Lee R, Ha H, Han YS, Jung MK, Chun JM. Predictive factors for long operative duration in patients undergoing laparoscopic cholecystectomy after endoscopic retrograde cholangiography for combined choledochocystolithiasis. Surg Laparosc Endosc Percutan Tech 2017; 27 (06) 491-496
    CrossrefPubMedGoogle Scholar
  • 36 Verzhbitsky V, Zeina AR, Depsames R, Ovadia B, Atia O, Fireman Z. Does prophylactic stent insertion to the common bile duct during endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy have any impact on the rate of biliary complications?. Surg Endosc 2013; 27 (12) 4620-4624
    CrossrefPubMedGoogle Scholar
  • 37 Kawabata H, Kawakatsu Y, Yamaguchi K. et al. Prophylactic biliary stenting before cholecystectomy in patients with gallstones and common bile duct stones. Gastroenterol Res 2019; 12 (04) 191-197
    CrossrefPubMedGoogle Scholar
  • 38 Nair MS, Uzzaman MM, Fafemi O, Athow A. Elective laparoscopic cholecystectomy in the presence of common bile duct stent. Surg Endosc 2011; 25 (02) 429-436
    CrossrefPubMedGoogle Scholar
  • 39 Cuschieri A. Ductal stones: pathology, clinical manifestations, laparoscopic extraction techniques, and complications. Semin Laparosc Surg 2016; 7 (04) 246-261
    CrossrefPubMedGoogle Scholar