It is technically challenging to perform intrahepatic choledochoscopy with a 3-mm choledochoscope due to its narrow gauge. The more rigid 5-mm scope is thus preferred, but is limited in TCE because its effective use depends on the presence of a dilated cystic duct. Despite the technical limitations of both caliber scopes, we have demonstrated that intrahepatic choledochoscopy during TCE is possible, with each, in 40 % of cases.
Objective: This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. Summary of Background Data: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. Methods: The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo-chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. Results: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. Conclusions: Choledochoscopy should always be performed during a chol-edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.
A 55-year-old female radiographer presented to the emergency department with acute onset of severe right iliac fossa pain. There had been a history of intermittent similar pain over the preceding 6 months, and she had been previously admitted to hospital with no cause found. There were no significant co-morbidities other than obesity. On this occasion, she was at work in the hospital when the pain began, and she was expediently transferred to the accident and emergency department. She was found to be tender in the right iliac fossa with guarding but no obvious mass was palpable. Inflammatory markers and plain abdominal X-ray were unremarkable. An urgent abdominal computed tomography (CT) scan was performed during which her pain resolved; by the time of surgical review 1 h later, she was pain-free with no clinical signs evident.The CT scan demonstrated an incarcerated spigelian hernia containing small bowel (Fig. 1). This had Timely computed tomography scan diagnoses spigelian hernia: a case study
Background Laparoscopic cholecystectomy is one of the most common operations in the UK, with around 60,000 performed in the UK each year. Large numbers of single use instruments are used in laparoscopic surgery, despite the availability of reusable and hybrid alternatives. A hybrid instrument is one where most of the instrument is reusable but it also has a single use replaceable component Operating theatres are a major carbon hotspot within healthcare. The NHS alone is estimated to be responsible for about 4% of England's carbon emissions, thought to be similar in Scotland and operating theatres account for up to 33% of solid waste produced in hospitals. The NHS has a target of reaching net zero emissions by 2040. There is a wide variability in surgical instruments use for laparoscopic cholecystectomy between operators and hospitals - our aim was to examine what was currently being used within 7 different hospital within a single health board, and to suggest the ‘greenest ’ possible instrument tray. It has already been shown that for a single procedure, the cost of using a hybrid laparoscopic clip appliers, scissors, and ports was 47% of that of single-use equivalents, and the carbon footprint 76% lower (Rizan 2021) Methods Visits to the 7 hospital sites currently performing laparoscopic cholecystectomy within a single health board was carried out by 3rd Year medical Student, as part of a Sustainability in Surgery SSC, during a 4 week period in May 2022. This was a snap shot audit and only one surgeon per site was visited. The items used during laparoscopic cholecystectomy were recorded with focus on the use of reusable, hybrid and single use tools. Costs and supplier information were gathered from theatre staff and company representatives. The relevant elements of the surgical tray setups were collated into a table and costs were compared. CO2 footprint was also collated when available. Results There was a wide variation in surgical set ups between hospitals within the same health board. 3 hospitals no longer had any reusable laparoscopic instruments and used all single use, the rest used a combination of single use, hybrid and disposable. All hospitals except one used single use laparoscopic ports- the other used hybrid ports. Most hospitals used single use clip appliers- one surgeon used ties instead. 2 hospitals used skin staples for skin closure. No single hospital utilised the most sustainable option in every item analysed. Costs were analysed below. Single use items were cheaper than reusables for nearly all key items but more expensive in the long term. Hybrid items had lower or similar costs to single use and much lower carbon emissions. Waste and decontamination costs were not taken into account in this analysis. Conclusions Taking the most sustainable practises from the hospitals we visited, an ‘ideal setup’ from an environmental viewpoint was devised using items already available within the health-board. We suggest that this be adopted to reduce both carbon emissions as well as costs. Where the upfront costs of purchasing new reusable instruments are prohibitive, hybrid instruments are recommended. Addressing simple things such as swapping low cost single use plastic item for their reusable counterparts is important and often overlooked. Using reusable instruments to the end of their lifespan, efficient decontamination and regular maintenance also play a role in reducing impact and costs. Further work is required by the healthcare sector and manufacturers to carry out environmental analyses for commonly used items and provide data upon which purchasing decisions could be made to improve sustainability and allow the NHS to meet its net zero target.
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