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Concept: Cystic duct


This review summarizes recent innovations in the approaches to gallbladder disease, including laparoscopic cholecystectomy, cholecystectomy with natural orifice transluminal endoscopic surgery, percutaneous cholecystostomy, and peroral endoscopic gallbladder drainage.

Concepts: Surgery, Laparoscopic surgery, Gallbladder, Cholecystectomy, Endoscopic retrograde cholangiopancreatography, Endoscopy, Common hepatic duct, Cystic duct


: To investigate the risk of intestinal cancer in a cohort of people who had undergone cholecystectomy for gallstones, and in a cohort of people who had been hospitalized for gallbladder disease but had not undergone cholecystectomy.

Concepts: Epidemiology, Cancer, Actuarial science, Liver, Hepatology, Gallbladder, Common hepatic duct, Cystic duct


Calculi in the cystic duct remnant are one of the causes of postcholecystectomy syndrome. A 36-year-old woman presented thrice to the casualty department with right upper quadrant pain at an interval of 2 months every time. Ultrasound and CT scan of the abdomen was normal except for echoes in the gallbladder region may be clips. She was treated conservatively and discharged the first two times. The second time, the MR cholangiopancreatography was normal. She had undergone endoscopic retrograde cholangiopancreatography with sphincterotomy with stent in situ outside elsewhere before presenting to us for the third time, which was removed after 6-weeks. The third time, she was taken up for laparoscopic stump exploration, which revealed a stone, which was the cause of her pain. To conclude, stump stone can be a possibility of post cholecystectomy syndrome even after 6 years, and surgeons should be aware of it.

Concepts: Abdomen, Gallbladder, Cholecystectomy, Endoscopic retrograde cholangiopancreatography, Endoscopy, Magnetic resonance cholangiopancreatography, Cystic duct, Postcholecystectomy syndrome


Abstract The current rate of bile duct injury (BDI) after laparoscopic cholecystectomy is 0.4%, which is an unacceptable outcome. Several surgical approaches have been suggested to mitigate the occurrence of this dreaded complication. We propose a standardized approach, using Calot’s node as a critical anatomical landmark to guide gallbladder dissection and avoid BDI. We retrospectively analyzed a prospectively gathered database of 907 laparoscopic cholecystectomies using this standardized approach in our practice over a 5-year period. To date we have had no BDI and no cystic duct leak. Therefore, we suggest identification of Calot’s node as an additional method to avoid BDI during laparoscopic cholecystectomy.

Concepts: Hepatology, Bile, Bile duct, Laparoscopic surgery, Cholecystectomy, Gallstone, Common hepatic duct, Cystic duct


Cirrhotic patients have been known to be more affected with gallstones than their non-cirrhotic counterparts; since laparoscopy was introduced, it has been generally approved as the standard approach for cholecystectomies with the exception of end-stage cirrhosis. The purpose of this study was to evaluate the safety and efficacy of clipless laparoscopic cholecystectomy using the harmonic scalpel in complicated cholelithiasis in cirrhotic patients.

Concepts: Surgery, Hepatology, Laparoscopic surgery, Cholecystectomy, Gallstone, Common hepatic duct, Cystic duct


The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a ‘delayed’ operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease.

Concepts: Medical terms, Hospital, Surgery, Cultural studies, Laparoscopic surgery, Cholecystectomy, Common hepatic duct, Cystic duct


The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all-cause 30-day readmissions and complications in a prospective population-based cohort.

Concepts: Cohort study, Epidemiology, Gallbladder, Common hepatic duct, Cystic duct


In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot’s triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvi√®re’s sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. This article is protected by copyright. All rights reserved.

Concepts: Hepatology, Bile duct, Laparoscopic surgery, Cholecystectomy, Common bile duct, Gallstone, Common hepatic duct, Cystic duct


The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Concepts: Cohort study, Epidemiology, Patient, Hospital, Physician, Common hepatic duct, Cystic duct, Carl Czerny


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.

Concepts: Digestive system, Liver, Hepatology, Bile, Bile duct, Cholecystectomy, Gallstone, Cystic duct