Routine versus selective intra-operative cholangiography during laparoscopic cholecystectomy Value and Consequences of Routine Intraoperative Cholangiography During Cholecystectomy Laparoscopic versus small-incision cholecystectomy: Health status in a blind randomised trial Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Does routine intraoperative cholangiography prevent bile duct transection? Conventional Versus laparoscopic cholecystectomy and the randomized controlled trial Non-randomised patients in a cholecystectomy trial: characteristics, procedures, and outcomes Routine early laparoscopic cholecystectomy for acute cholecystitis after conclusion of a randomized controlled trial Consequences of routine peroperative cholangiography during cholecystectomy for gallstone disease: A prospective, randomized study Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial Laparoscopic or open cholecystectomy: a prospective randomised trial to compare postoperative pain, pulmonary function, and stress response. Double-blind randomized sham controlled trial of intraperitoneal bupivacaine during emergency laparoscopic cholecystectomy. Routine cholangiography is not warranted during laparoscopic cholecystectomy. Randomized clinical trial of single‐ versus multi‐incision laparoscopic cholecystectomy The HAC trial (harmonic for acute cholecystitis): a randomized, double-blind, controlled trial comparing the use of harmonic scalpel to monopolar diathermy for laparoscopic cholecystectomy in cases of acute cholecystitis The ACTIVE (Acute Cholecystitis Trial Invasive Versus Endoscopic) study: Multicenter randomized, double-blind, controlled trial of laparoscopic (LC) versus open (LTC) surgery for acute cholecystitis (AC) in adults Surgical outcome in patients with primary sclerosing cholangitis undergoing ileal pouch-anal anastomosis: a case-control study.
Opinion is divided whether intra-operative cholangiography should be performed routinely or on a selective basis during laparoscopic cholecystectomy . We therefore performed the first prospect i ve r and omized trial of static cholangiography in patients who did not have indications for cholangiograms .  Laparoscopic cholecystectomy  was attempted on 164 consecutive patients , of whom 49 ( 30 % ) patients were excluded from the trial due to indications for or against cholangiography .  In the remaining 115 ( 70 % ) patients , 56 were r and omized to the cholangiography group while 59 patients did not receive cholangiograms .  Duration of postoperative hospitalization and interval to return to full activity were identical in the two groups . Static cholangiograms added 16 ± 1 min ( mean ± SEM ) to the procedures ( p<0.01 ) . Cholangiography  increased the total charges for the operation by almost $ 700 ( p<0.01 ) . Cholangiograms were performed successfully in 94.6 % of the patients and changed the operative management in 4 ( 7.5 % ) patients . There was 1 ( 1.9 % ) false negative study . Intra-operative cholangiography did not reveal aberrant bile ducts at risk of injury from the operative dissection . There was no mortality or cholangiogram-related morbidity in either group . In follow-up ranging from 2–12 months , there has been no clinical evidence of bile duct injury or retained common bile duct stones . In summary , in patients without indications for cholangiography , the performance of static cholangiograms markedly increased the operative time and cost of laparoscopic cholecystectomy  . The operative management of a minority of patients was changed by the information obtained , but laparoscopic cholecystectomy may be performed safely in the absence of cholangiograms with little risk of injury to the major ductal system or retained calculi . RésuméLes avis sont partagés quant à la pratique systématique , ou seulement élective , d'une cholangiographie lors de la cholécystectomie coelioscopique . Nous avons mené le premier essai r and omisé prospect if de cholangiographie peropératoire chez des patients n'ayant pas d'indication formelle de cholangiographie . Dans une série de 164 cholécystectomies coelioscopiques consécutives , 49 patients ( 30 % ) ont été éliminés de l'étude parce qu'il existait une indication ou une contreindication formelles à la cholangiographie peropératoire . Les 115 patients restants ( 70 % ) ont été r and omisés ; 56 ont eu une cholangiographie alors que 59 n'ont pas eu de cholangiographie peropératoire . La durée de l'hospitalisation postopératoire et le délai entre l'intervention et la reprise de travail étaient similaires dans les deux groupes . La cholangiographie a prolongé l'intervention de 16 ± 1 min ( moyenne ± écart type de la moyenne ) ( p<0.01 ) . Le coût supplémentaire d'une cholangiographie peropératoire a été estimé à environ 700 $ US ( p<0.01 ) . La cholangiographie a pu être effectuée chez 94.6 % des patients , et celle-ci a changé la tactique opératoire chez 4 ( 7.5 % ) patients . Il y a eu un résultat faussement négatif ( 1.9 % ) . La cholangiographie peropératoire n'a pas montré d'anomalie anatomique des voies biliares pouvant les compromettre lors de la dissection . La mortalité a été nulle dans chaque groupe . De même , il n'y a eu aucune morbidité en rapport direct avec la cholangiographie . Dans la période du suivi allant de 2 à 12 mois , il n'y a eu acune lésion biliaire ni de lithiase résiduelle de la voie biliaire cliniquement évidentes . En conclusion , chez un patients ans indication formelle de cholangiographie , la réalisation d'une cholangiographie peropératoire augmente considérablement la durée et le coût de l'intervention . La tactique opératoire a été très peu influencée très peu par les donées de la cholangiographie . La cholécystectomie coelioscopique peut être réalisée sans cholangiographie peropératoire systématique sans augmenter pour autant le risque de lésions des voies biliaires ou de calcul résiduel . ResumenLas opiniones se encuentran divididas respecto a si se debe realizar colangiografía intraoperatoria en forma rutinaria o en forma selectiva en el curso de una colecistectomía laparoscópica . Por ello hemos realizado el primer estudio aleatorizado de colangiografía estática en pacientes que no tenían indicaciones para colangiograma . Se intentó la colecistectomía laparoscópica en 164 pacientes consecutivos ; 49 ( 30 % ) fueron excluidos debido a indicaciones en favor o en contra de colangiografía . Los otros 115 pacientes ( 70 % ) se repartieron al azar 56 a colangiografía y 59 al grupo de no colangiografía . La duración de la hospitalización postoperatoria y del tiempo de retorno a actividad normal fueron idénticos en los dos grupos . Los colangiogramas estáticos añadieron 16 ± 1 min . al procedimiento ( p<0.01 ) y elevaron el costo de la operación en $ 700 ( p<0.01 ) . Los colangiogramas fueron exitosamente realizados en 49.6 % de los pacientes y modificaron el manejo operatorio en 4 ( 7.5 % ) ; hubo un falso positivo ( 1.9 % ) . La colangiografía intraoperatoria no reveló la prescencia de canales biliares aberrantes en riesgo de lesión por la disección opeatoria . No hubo mortalidad o morbilidad relacionada con la colangiografía , y en un seguimiento de 2–12 meses no se registró evidencia clínica de lesión de canales biliares o de cálculos retenidos en el colédoco . En resumen , en pacientes sin indicaciones para colangiografía , la realización de colangiogramas estáticos aumentó notoriamente el tiempo operatorio y el costo de la colecistectomia laparoscópica . Aunque el manejo operatorio de una minoría de pacientes sí fue modificado por la información obtenida , se considera que la colecistectomía laparoscópica puede ser practicada en forma segura en ausencia de colangiogramas con mínimo riesgo de lesión del sistema biliar o de cálculos retenidos Since the introduction of laparoscopic cholecystectomy ( LC ) , an increase in accidental  common bile duct ( CBD )  injuries of up to 1.2–1.6 % has been reported . In the present prospect i ve study of 1,710 patients undergoing cholecystectomy ( 1,241 LC procedures and 469 open cholecystectomies [ OC ] ) , we tested the predicative value of routine intraoperative cholangiography ( IOC ) . The IOC was feasible in 92.4 % of the cases in the LC group and in 83 % of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3 % . Anatomic variations of the bile duct system , which influenced the operative management , were found in 13.2 % of cases ( 13.4 % LC versus 12.8 % OC ) . In 2.5 % of the patients , preoperatively undetected CBD stones were also found . Method -specific complications did not occur in any of the patients . Additionally , in a controlled subgroup analysis of 163 patients , we evaluated preoperative intravenous cholangiography ( IVC ) and IOC . Intravenous cholangiography showed only 72.4 % of the operation-relevant anatomic variations ( vs. 100 % by IOC ) ; in 6.1 % of the cases , there were reactions to the dye ( vs. none in IOC ) , and in only 28.6 % of the patients , CBD stones were detected ( vs. 71.4 % IOC ) . There were four bile duct injuries ( 0.29 % ) during LC and two ( 0.4 % ) during OC . All injuries were detected intraoperatively and fixed in the same setting without postoperative complications . In conclusion , we recommend the use of routine IOC during cholecystectomy . By this technique , anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided Background Gallstones are a major cause of morbidity , and cholecystectomy is a commonly performed procedure . Minimal invasive procedures , laparoscopic cholecystectomy ( LC ) and small-incision cholecystectomy ( SIC ) , have replaced the classical open cholecystectomy . No differences have been found in primary outcome measures between LC and SIC , therefore secondary outcome measures have to be considered to determine preferences . The aim of our study was to examine health status applying evidence -based guidelines in LC and SIC in a r and omised trial . Methods Patients with symptomatic cholecystolithiasis were included in a blind r and omised trial . Operative procedures , anaesthesia , analgesics and postoperative care were st and ardised in order to limit bias . Question naires were filled in preoperatively , the first day postoperatively , and at out patients follow-up at 2 , 6 and 12 weeks . In accordance with evidence -based guidelines , the generic short form ( SF-36 ) and the disease-specific gastrointestinal quality -of-life index ( GIQLI ) question naires were used in addition to the body image question naire ( BIQ ) . Results A total of 257 patients were r and omised between LC ( 120 ) and SIC ( 137 ) . Analyses were performed according to intention-to-treat ( converted procedures included ) and also distinguishing converted from minimal invasive ( nonconverted ) procedures . Question naires were obtained with a response rate varying from 87.5 % preoperatively to 77.4 % three months postoperatively . Except for two time-specific measurements in one SF-36 subscale , there were no differences between LC and SIC . There were significant differences in several subscales in all three question naires comparing minimal invasive versus converted procedures . Conclusions Applying adequate method ological quality and evidence -based guidelines ( by using SF-36 and GIQLI ) , there are no significant differences in health status between LC and SIC HYPOTHESIS Magnetic resonance cholangiography ( MRC ) offers the potential for accurate , noninvasive detection of  common bile duct stones ( CBDSs ) before cholecystectomy , and for a consequent reduction in the incidence of preoperative negative diagnoses associated with endoscopic retro grade cholangiography ( ERC ) . DESIGN Prospect i ve cohort study : MRC results were correlated with ERC ( high-risk patients ) or intraoperative cholangiography ( moderate-risk patients ) . SETTING A university hospital providing primary , secondary , and tertiary care . PATIENTS Seventy patients with suspected CBDSs scheduled to undergo elective cholecystectomy between April 15 , 1997 , and September 30 , 1998 . Forty patients were considered at high risk and 30 at moderate risk for CBDSs , according to results of liver function tests and sonograms of the upper abdomen . MAIN OUTCOME MEASURES Confirmation or exclusion of CBDSs by MRC  was assessed by a panel of radiologists who were unaware of the ERC results . Results of ERC and intraoperative cholangiography were analyzed by the investigating gastroenterologists or surgeon . RESULTS Results of MRC were positive for CBDSs in 21 ( 52 % ) of 40 high-risk patients , a finding confirmed by preoperative ERC in 19 ( 90 % ) of 21 patients . Results of MRC were positive for CBDSs in 6 ( 20 % ) of 30 moderate-risk patients , all of which were confirmed by intraoperative cholangiography . Finally , CBDSs were present in 19 ( 48 % ) of 40 high-risk patients and 6 ( 20 % ) of 30 moderate-risk patients ( P = .02 ) . Overall sensitivity and specificity of  MRC  were 100 % and 95.6 % , respectively ; the positive and negative predictive values were 92.6 % and 100 % , respectively . CONCLUSIONS Magnetic resonance cholangiography is a reliable , noninvasive method for the detection or exclusion of CBDSs , and seems to reduce the frequency of negative diagnoses associated with ERC . Magnetic resonance cholangiography revealed no CBDSs in 19 ( 48 % ) of 40 patients at high risk for CBDSs . Thus , MRC-based diagnosis has the potential to reduce the number of invasive preoperative diagnostic procedures and their associated risks and overall health care costs Background The role of routine intraoperative cholangiography is controversial . The aim of this study was to assess the impact of routine intraoperative cholangiography on the incidence of common bile duct injuries , and to evaluate the operative outcome of laparoscopic cholecystectomy carried out in a major teaching hospital and review the literature . Methods Prospect ively collected data on 3,145 laparoscopic cholecystectomies performed mainly by surgical trainees in the period 1990 to 2002 using routine intraoperative cholangiography with fluoroscopy were review ed . Results The mean age of the study sample ( 65.6 % male , 34.4 % female ) was 54 years , and 16.9 % of the patients had clinical acute cholecystitis . The conversion rate to open cholecystectomy was 4.3 % . Intraoperative cholangiography was attempted for 90.7 % of the patients with a 95.9 % success rate . Five patients ( 0.16 % ) had common bile duct injuries . Four injuries had occurred in the first 5 years . One injury ( 0.06 % ) had occurred after 1995 . This injury was identified intraoperatively and repaired laparoscopically . Routine intraoperative cholangiography prevented one definite common bile duct transection . Conclusions In this series using routine intraoperative cholangiography , there was a low rate and severity of common bile duct injuries , with a high intraoperative recognition rate . There was no bile duct transection or major injury requiring common bile duct reconstruction . Although intraoperative cholangiography helped in the immediate identification of injuries and the institution of appropriate therapy , injury was not completely prevented We considered using a r and omized trial to assess the value of laparoscopic cholecystectomy in the treatment of symptomatic gallstones . The pros and cons for the timing of such a trial were in favour of not beginning the trial until surgeons learned to use the new procedure safely and effectively , and until key endpoints and outcome indices could be identified and assessed using valid measures . Instead an observational study was implemented to monitor the learning curve of surgeons as they mastered the laparoscopic equipment and procedures , and to assess the responses of the patients to the procedure . In the first 100 patients , the procedure proved to be as safe and feasible to use as conventional surgery , and there were strong benefits in terms of quicker recovery of the patients with less pain , discomfort , and a reduced length of hospital stay . The responses of the surgeons and the patients to the new procedure now place ethical constraints on the planning of a r and omized controlled trial . Currently , comprehensive surveillance and monitoring of laparoscopic cholecystectomy is the only realistic method with which to assess the impact of this new technology in our clinic Background Laparoscopic cholecystectomy is now considered the first option for gallbladder surgery . However , 20 % to 30 % of cholecystectomies are completed as open operations often on elderly and fragile patients . The external validity of r and omised trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy has not been studied . The aim of this study is to analyse characteristics , procedures , and outcomes for all patients who underwent cholecystectomy without being included in such a trial . Methods Characteristics ( age , sex , co-morbidity , and ASA-score ) , operation time , hospital stay , and mortality were compared for patients who underwent cholecystectomy outside and within a r and omised controlled trial comparing mini-laparotomy and laparoscopic cholecystectomy .  Results During the inclusion period 1719 patients underwent cholecystectomy . 726 patients were r and omised and 724 of them completed the trial ; 993 patients underwent cholecystectomy outside the trial . The non-r and omised patients were older – and had more complications from gallstone disease , higher co-morbidity , and higher ASA – score when compared with trial patients . They were also more likely to undergo acute surgery and they had a longer postoperative hospital stay , with a median 3 versus 2 days ( p < 0.001 for all comparisons ) . St and ardised mortality ratio within 90 days of operation was 3.42 ( mean ) ( 95 % CI 2.17 to 5.13 ) for non-r and omised patients and 1.61 ( mean ) ( 95%CI 0.02 to 3.46 ) for trial patients . For non-r and omised patients , operation time did not differ significantly between mini-laparotomy and open cholecystectomy in multivariate analysis . However , the operation for laparoscopic cholecystectomy lasted 20 minutes longer than open cholecystectomy . Hospital stay was significantly shorter for both mini-laparotomy and laparoscopic cholecystectomy compared to open cholecystectomy . Conclusion Non-r and omised patients were older and more sick than trial patients . The assignment of healthier patients to trials comparing mini-laparotomy cholecystectomy and laparoscopic cholecystectomy limits the external validity of conclusions reached in such trials The aim of this retrospective review was to assess the clinical outcomes of  laparoscopic cholecystectomy  for acute cholecystitis since the conclusion of a r and omized controlled trial in 1997 To assess the value of routine peroperative cholangiography ( PC ) , 457 patients undergoing cholecystectomy for gallstone disease were prospect ively screened for the presence of 11 predefined criteria indicating possible choledocholithiasis . Two hundred and eighty patients who had no positive criteria and in whom preoperative endoscopic retro grade cholangiography ( ERC ) had not been performed were r and omized to PC or no PC .  The patients were followed up 12 months postoperatively , and those who had signs or symptoms of possible retained common bile duct calculi were referred to ERC . The difference in mean operative time between the 2 treatment groups was 23.3 minutes . Four patients ( 2.8 % ) in the PC group had unsuspected common bile duct calculi , and in 3 patients ( 2.1 % ) , the PC was false-positive . On follow-up , no case of retained common bile duct calculi was found in either group . The rate of postoperative complications was significantly higher in the PC group than in the non-PC group . It is concluded that PC should be performed only in patients with indications of common bile duct disease or in whom clarification of the anatomy is necessary . RésuméPour apprécier la valeur de la cholangiographie opératoire de routine , 457 sujets subissant une cholécystectomie pour lithiase vésiculaire ont été étudiés prospect ivement en fonction de 11 critères de présomption de lithiase cholédocienne . Deux cent quatre-vingts d'entre eux qui ne présentaient pas un critère de présomption et chez qui n'avait pas été pratiquée une cholangiographie rétro grade endoscopique ont été soumis à une cholangiographie opératoire à la suite d'un choix par tirage au sort . Ils furent ensuite suivis pendant une période de 12 mois au décours de l'intervention de manière que ceux qui présentaient des symptômes et des signes en faveur de la présence de calculs oubliés dans le cholédoque fussent soumis à une cholangiographie rétro grade endoscopique . Premier élément , la durée de l'intervention fut augmentée en moyenne de 23.3 minutes lorsque fut pratiquée la cholangiographie opératoire . Quatre malades ( 2.8 % ) ainsi explorés présentaient des calculs cholédociens . Trois cas de faux positifs ( 2.1 % ) furent enregistrés . Aucun cas de lithiase résiduelle n'a été découvert dans les 2 groupes . Le taux des complications postopératoires fut plus élevée lorsque la cholangiographie opératoire fut pratiquée . On peut conclure de ces faits , que cette exploration doit Être proposée seulement lorsque la présence de calculs dans la voie biliare principale est à envisager ou qu and il est nécessaire de préciser l'anastomie des voies biliares . ResumenCon el objeto de determinar el valor de la colangiografía peroperatoria ( CP ) , 457 pacientes programados para colecistectomía por enfermedad litiásica biliar fueron preoperatoriamente tamizados para establecer la presencia de 11 criterios predefinidos indic and o posible coledocolitiasis . Doscientos ochenta pacientes que no presentaban criterios positivos y en quienes la colangiografía retrógrada endoscópica ( CRE ) no había sido practicada fueron asignados al azar a CP o a no CP . Los pacientes fueron seguidos por 12 meses después de la operación , y aquellos con signos o síntomas de posibles cálculos retenidos en el colédoco fueron referidos para CRE . La diferencia en el tiempo operatorio promedio entre los 2 grupos fue de 23.3 minutos . Cuatro pacientes ( 2.8 % ) en el grupo con CP presentaron cálculos inesperados en el colédoco , y en 3 casos ( 2.1 % ) , la CP result ó falsapositiva . En el curso del seguimiento , ningÚn caso de cálculos retenidos en el colédoco fue hallado en uno u otro grupo . La tasa de complicaciones postoperatorias fue significativamente mayor en el grupo con CP que en el grupo sin CP . Se concluye que la CP debe ser practicada sólo en pacientes con criterios de patología coledociana o en quienes sea necesario clarificar la anatomía Background The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery ( NOTES ) and single-incision laparoscopic surgery ( SILS ) . These new techniques are considered to be painless procedures , but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy . In this r and omized control study , we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy . Patients and methods Forty patients ( 34 women and 6 men ) were r and omly assigned to two groups . In group A ( n = 20 ) four-port classic laparoscopic cholecystectomy was performed . Patients in group B ( n = 20 ) underwent SILS cholecystectomy .  In all patients , preincisional local infiltration of ropivacaine around the trocar wounds was performed . Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well . Shoulder tip and abdominal pain were registered at 2 , 6 , 12 , 24 , 48 , and 72 h postoperatively using visual analog scale ( VAS ) . Results Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain , and after the first 6 h for shoulder pain . Total pain after the first 24 h was nonexistent in the SILS group . Also , requests for analgesics were significantly less in the SILS group , while no difference was observed in incidence of nausea and vomiting between the two groups . ConclusionS ILS cholecystectomy , as well as the invisible scar , has significantly lower abdominal and shoulder pain scores , especially after the first 24 h postoperatively , when this pain is nonexistent . ( Registration Clinical Trial number : NTC00872287 , www . clinical trials.gov ) OBJECTIVE Open cholecystectomy ( OC ) has been superseded by laparoscopic cholecystectomy ( LC ) for the treatment of cholelithiasis , although this fashion has not been vali date d by prospect i ve studies . Our aim was to compare the two techniques . DESIGN Prospect i ve , r and omised , open study . SETTING University hospital , Finl and . PATIENTS 49 patients who required cholecystectomy for cholelithiasis confirmed by ultrasound . INTERVENTIONS 49 patients were r and omly allocated to LC ( n = 27 ) or OC ( n = 22 ) : 25 and 22 , respectively , eventually had the operation . LC was done using a four-trocar technique , and OC through a transverse right subcostal incision , as short as possible . MAIN OUTCOME MEASURES Length of hospital stay and the duration of the sick leave were the primary outcome measures . Secondary outcome measures were : postoperative pain evaluated by visual analogue scale ( VAS ) and the need for opioids ; pulmonary function measured by forced vital capacity ( FVC ) , forced expiratory volume in one second ( FEV1 ) , peak flow velocity ( PEFV ) , and arterial oxygen tension ( PaO2 ) , and endocrine stress measured by plasma catecholamines , cortisol and glucose concentrations . RESULTS The median ( range ) hospital stay was significantly shorter after LC than OC , being 2.0 ( 1 - 15 ) compared with 4.5 ( 2 - 19 ) days p < 0.01 . The duration of sick leave was also significantly shorter after LC than OC , being 14 ( 7 - 17 ) compared with 29 ( 4 - 34 ) , p < 0.01 . Patients had significantly less postoperative pain after LC than OC as reflected by the need for opioids . Pulmonary function and arterial oxygen tension deteriorated significantly less after LC than OC . The stress response was equal . There were three documented complications , one pneumonia after LC and two wound infections after OC . CONCLUSIONS LC gives significantly better results in terms of less postoperative pain , better pulmonary function , better arterial oxygenation , and shorter hospital stay and duration of sick leave BACKGROUND Intraperitoneal local anesthesia ( IPLA ) during elective laparoscopic cholecystectomy ( el-LC ) decreases post-operative pain . None of the studies have explored the efficacy of IPLA at emergency laparoscopic cholecystectomy ( em-LC ) . A longer operative duration , the greater frequency of washing , and the inflammation associated with cholecystitis or pancreatitis are a few reasons why it can not be assumed that a benefit in pain scores will be seen in em-LC with IPLA . This study was undertaken to assess the efficacy of IPLA in patients undergoing em-LC . METHODS Double-blind r and omized sham controlled trial was conducted of 41 consecutive subjects undergoing em-LC . IPLA was delivered by a combination of injection to the diaphragmatic and topical wash over the liver and gallbladder with bupivacaine or saline . The primary outcome was visual analogue scale pain scores until discharge . Secondary outcomes included pain scores in theatre recovery and analgesic consumption . RESULTS One patient had a procedure converted to open and was excluded . There was no significant difference in pain scores in the ward or theatre recovery . Analgesic use , respiratory rate , oxygen saturation , duration to ambulation , eating , satisfaction scores , and time to discharge were comparable between the two groups . CONCLUSIONS IPLA during em-LC does not influence postoperative pain . Other modalities of analgesia should be explored for decreasing the interval between diagnosis of acute admission and em-LC The role of intraoperative cholangiography during laparoscopic cholecystectomy was prospect ively evaluated in 514 patients undergoing laparoscopic cholecystectomy .  Before surgery , all patients were assigned to one of three groups depending on the likelihood of their having common bile duct stones . Stratification was based on objective historical , laboratory , or radiologic criteria . In 453 patients deemed unlikely to have stones , laparoscopic cholecystectomy was performed without cholangiography . Of these patients , four had retained stones ( 0.9 % ) . In 25 patients likely to have stones , preoperative endoscopic retro grade cholangiopancreatography identified stones in six patients ( 24 % ) . In 36 patients whose likelihood of having stones was deemed indeterminate , intraoperative cholangiography was performed at laparoscopic cholecystectomy . A common bile duct stone was identified in one patient ( 2.8 % ) . One common bile duct injury occurred in the group deemed unlikely to have stones , and this injury would not have been prevented by intraoperative cholangiography . We conclude that preoperative assessment will identify common bile duct stones and that routine cholangiography is not warranted . Meticulous dissection of the cystic duct at its origin at the infundibulum will prevent common bile duct injury There are no r and omized studies that compare outcomes after  single‐incision ( SLC ) and conventional multi‐incision ( MLC ) laparoscopic cholecystectomy  under an optimized perioperative analgesic regimen Background The HARMONIC SCALPEL ( H ) is an advanced ultrasonic cutting and coagulating surgical device with important clinical advantages , such as : reduced ligature dem and ; greater precision due to minimal lateral thermal tissue damage ; minimal smoke production ; absence of electric corrents running through the patient . However , there are no prospect i ve RCTs demonstrating the advantages of H compared to the conventional monopolar diathermy ( MD ) during laparoscopic cholecystectomy ( LC ) in cases of acute cholecystitis ( AC ) . Methods This study was a prospect i ve , single-center , r and omized trial ( Trial Registration Number : NCT00746850 ) design ed to investigate whether the use of H can reduce the incidence of intra-operative conversion during LC in cases of AC , compared to the use of MD . Patients were divided into two groups : both groups underwent early LC , within 72 hours of diagnosis , using H and MD respectively ( H = experimental/ study group , MD = control group ) . The study was design ed and conducted in accordance with the regulations of Good Clinical Practice . Results 42 patients were r and omly assigned the use of H ( 21 patients ) or MD ( 21 patients ) during LC . The two groups were comparable in terms of basic patient characteristics . Mean operating time in the H group was 101.3 minutes compared to 106.4 minutes in the control group ( p = ns ) ; overall blood loss was significantly lower in the H group . Conversion rate was 4.7 % for the H group , which was significantly lower than the 33 % conversion rate for the control group ( p<0.05 ) . Post-operative morbidity rates differed slightly : 19 % and 23 % in the H and control groups , respectively ( p = ns ) . Average post-operative hospitalization lasted 5.2 days in the H group compared to 5.4 days in the control group ( p = ns ) . Conclusions The use of H appears to correlate with reduced rates of laparoscopic-open conversion . Given this evidence , H may be more suitable than MD for technically dem and ing cases of AC Background In some r and omized trials successful laparoscopic cholecystectomy for cholecystitis is associated with an earlier recovery and shorter hospital stay when compared with open cholecystectomy . Other studies did not confirm these results and showed that the potential advantages of laparoscopic cholecystectomy for cholecystitis can be offset by a high conversion rate to open surgery . Moreover in these studies a similar postoperative programme to optimize recovery comparing laparoscopic and open approaches was not st and ardized . These studies also do not report all eligible patients and are not double blinded . Design The present study project is a prospect i ve , r and omized investigation . The study will be performed in the Department of General , Emergency and Transplant Surgery St Orsola-Malpighi University Hospital ( Bologna , Italy ) , a large teaching institutions , with the participation of all surgeons who accept to be involved in ( and together with other selected centers ) . The patients will be divided in two groups : in the first group the patient will be su bmi tted to laparoscopic cholecystectomy within 72 hours after the diagnosis while in the second group will be su bmi tted to laparotomic cholecystectomy within 72 hours after the diagnosis . Trial Registration TRIAL REGISTRATION NUMBER IS RCT N27929536 – The ACTIVE ( Acute Cholecystitis Trial Invasive Versus Endoscopic ) study . A multicentre r and omised , double-blind , controlled trial of laparoscopic versus open surgery for acute cholecystitis in adults BACKGROUND The outcome of restorative proctocolectomy in the setting of chronic ulcerative colitis complicated by primary sclerosing cholangitis ( PSC ) is not clear . The purpose of this study was to determine the surgical outcome , risk of dysplasia/cancer , morbidity/mortality , long-term results , and functional and quality of life results in patients with inflammatory bowel disease ( IBD ) and PSC who underwent restorative proctocolectomy with ileal pouch-anal anastomosis and compare them in a case-matched study . METHODS Patients with PSC-associated IBD undergoing restorative proctocolectomy between 1983 and 2002 were included in the study . This study group was matched for age , gender , diagnosis , duration of disease , anastomosis technique , and proximal diversion to a cohort of IBD patients with no associated PSC who underwent restorative proctocolectomy during the same period of time . Postoperative morbidity , incidence of neoplasia/cancer in the resected specimen , pouchitis , pouch failure , long-term mortality , and 5-year survival rates were compared between the groups . The functional and quality of life records were prospect ively collected and compared between the groups . For each group , matched Kaplan-Meier survival analysis was also conducted comparing 5-year survival between the 2 cohorts , matching for diagnosis , duration of disease , age , gender , anastomosis type , and proximal diversion . RESULTS Sixty-five patients with PSC and IBD underwent restorative proctocolectomy with ileal pouch-anal anastomosis during the study period . Two hundred sixty IBD patients with no associated PSC who matched with the outlined criteria comprised the control group . The follow-up period was 68 + /- 50 months for the PSC group and 102 + /- 62 months for the control group . A higher incidence of cancer ( 14 % vs 5 % , P = .02 ) and dysplasia in the resected specimen ( 40 % vs 7 % , P < .001 ) , an associated increased risk of postoperative pelvic sepsis ( 14 % vs 5 % , P = .02 ) , and higher long-term mortality ( 35 % vs 4 % , P < .001 ) were found in the PSC group compared with control group with no associated PSC . The majority , 13 of 23 ( 57 % ) , of the deaths in the PSC group were a result of liver disease . Five-year survival for the PSC group was significantly poorer than the 5-year survival for the control group with no associated PSC . No significant differences were found in functional and quality of life results between the groups in the short- and long-term follow-up periods . CONCLUSIONS PSC-associated IBD patients after restorative proctocolectomy have a higher risk of neoplasia/cancer in the resected specimen , postoperative pelvic sepsis , and higher long-term mortality . Functional and quality of life remains similar in IBD patients after restorative proctocolectomy with or without associated PSC in the follow-up . However , patients with IBD and PSC have a significantly poorer survival than patients with no associated PSC after restorative proctocolectomy
N-OTC is associated with shorter operative time and fewer peri-operative complications , and it is comparable to R-OTC in terms of CBD injury risk during cholecystectomy .
R-OTC is helpful for peri-operative CBD stone detection and there is therefore reduced readmission for retained CBD stones .
The N-OTC approach may be adopted routinely for patients undergoing laparoscopic cholecystectomy providing there are no clinical , biochemical or radiological features suggestive of CBD stones .
INTRODUCTION The aim of this review was to systemically analyse trials evaluating the efficacy of routine on-table cholangiography ( R-OTC ) versus no on-table cholangiography ( N-OTC ) in patients undergoing cholecystectomy .