Title: Laparoscopic Cholecystectomy: Technique, Complications, and Clinical Significance
Author: David Maiolo
Laparoscopic cholecystectomy has become the preferred surgical procedure for treating gallbladder disease since its introduction in the early 1990s. This minimally invasive technique has largely replaced the open cholecystectomy technique. The purpose of this paper is to provide an overview of laparoscopic cholecystectomy, including its indications, contraindications, equipment, personnel, preparation, technique, complications, and clinical significance. The paper also emphasizes the importance of interprofessional team communication and collaboration in achieving optimal outcomes for patients undergoing laparoscopic cholecystectomy.
Keywords: laparoscopic cholecystectomy, gallbladder, surgical technique, complications, clinical outcomes, interprofessional collaboration, biliary disease, minimally invasive surgery.
A. Background and Significance
Cholecystectomy is one of the most common surgical procedures performed worldwide, with approximately 300,000 cholecystectomies being performed annually in the United States alone. Laparoscopic cholecystectomy has largely replaced open cholecystectomy as the preferred method for routine gallbladder surgery since the early 1990s. This minimally invasive technique involves the removal of the gallbladder using a laparoscope, which reduces postoperative pain, improves recovery time, and results in less scarring. Laparoscopic cholecystectomy has become the standard of care for gallbladder disease, including acute and chronic cholecystitis, symptomatic cholelithiasis, biliary dyskinesia, acalculous cholecystitis, gallstone pancreatitis, and gallbladder masses or polyps. However, despite the advantages of this technique, it is not without risks and potential complications. This paper aims to provide an overview of laparoscopic cholecystectomy, including its indications, contraindications, technique, and potential complications, as well as the role of the interprofessional team in its management.
B. Purpose of the Paper
The purpose of this paper is to provide an overview of laparoscopic cholecystectomy, including its indications, contraindications, technique, and potential complications. The paper also aims to highlight the importance of careful planning and discussion among the interprofessional team members involved in the management of patients undergoing laparoscopic cholecystectomy, in order to optimize patient outcomes.
II. Anatomy and Physiology
The gallbladder is a small pear-shaped organ that plays an important role in the digestive system by storing and releasing bile, a fluid produced by the liver that helps digest fats. The organ is located on the inferior surface of the liver and can hold up to 50 cc of bile. The bile is released into the small intestine through the common bile duct when food containing fat is ingested.
A. Location of the gallbladder
The gallbladder is a small, pear-shaped organ located on the underside of the liver, in the right upper quadrant of the abdomen. It is situated between the right and quadrate lobes of the liver and is in close proximity to the duodenum. The gallbladder is approximately 7-10 centimeters long and has a capacity of 30-50 milliliters when filled with bile. The gallbladder is attached to the liver by a connective tissue called the cystic duct, which carries bile from the gallbladder to the common bile duct.
B. Anatomical sections of the gallbladder
The gallbladder can be divided into three anatomical sections: the fundus, the body, and the neck. The fundus is the rounded portion of the gallbladder that protrudes from the inferior border of the liver. The body is the main portion of the gallbladder and is located between the fundus and the neck. The neck is the narrowest portion of the gallbladder and connects to the cystic duct.
C. Biliary ductal anatomy
The biliary system is a complex network of ducts that carries bile from the liver to the small intestine. The common bile duct is formed by the junction of the cystic duct and the common hepatic duct. The common hepatic duct originates from the liver and is formed by the confluence of the left and right hepatic ducts. The cystic duct, as mentioned earlier, connects the gallbladder to the common bile duct. The common bile duct then joins the pancreatic duct before emptying into the duodenum.
D. Blood supply to the gallbladder
The gallbladder receives its blood supply from the cystic artery, which is a branch of the right hepatic artery. The cystic artery runs along the cystic duct and supplies blood to the gallbladder and the cystic duct. The cystic vein drains the blood from the gallbladder and empties into the portal vein.
E. Surgical anatomical landmark (triangle of Calot)
The triangle of Calot is an important anatomical landmark in gallbladder surgery. It is formed by the cystic duct, the common hepatic duct, and the inferior border of the liver. The cystic artery runs through this triangle and is an important structure that must be identified and ligated during gallbladder surgery. Injury to the cystic artery can result in significant bleeding and other complications. Identification and preservation of the triangle of Calot is critical for safe and effective gallbladder surgery.
The decision to perform a cholecystectomy is based on the indication for the surgery. The most common indications include cholecystitis, symptomatic cholelithiasis, and biliary dyskinesia. Cholecystitis, which can be acute or chronic, refers to inflammation of the gallbladder. It is usually caused by obstruction of the cystic duct by gallstones, leading to buildup of bile in the gallbladder and subsequent inflammation. Symptoms of cholecystitis include severe right upper quadrant pain, fever, and nausea/vomiting. If left untreated, cholecystitis can lead to serious complications such as gangrene, perforation, or abscess formation. Surgery is usually indicated for acute cholecystitis, and often for chronic cholecystitis as well.
Symptomatic cholelithiasis is another common indication for cholecystectomy. This condition refers to the presence of gallstones in the gallbladder that cause symptoms such as right upper quadrant pain, nausea, and vomiting. Gallstones can also cause complications such as biliary colic, choledocholithiasis (stones in the common bile duct), and gallstone pancreatitis. Surgery is generally recommended for patients with symptomatic cholelithiasis to prevent these complications.
Biliary dyskinesia is a less common indication for cholecystectomy, but can be a source of significant morbidity for affected patients. This condition refers to impaired gallbladder contractility and emptying, leading to symptoms such as right upper quadrant pain, nausea, and vomiting. The diagnosis is made based on abnormal gallbladder ejection fraction on a HIDA scan. Surgery can be curative in patients with biliary dyskinesia and refractory symptoms.
Other indications for cholecystectomy include acalculous cholecystitis (inflammation of the gallbladder without gallstones), gallstone pancreatitis (pancreatitis caused by gallstones), and gallbladder masses/polyps. In general, these conditions are less common indications for surgery and require careful consideration on a case-by-case basis.
A. Cholecystitis (acute/chronic)
Acute cholecystitis is characterized by the inflammation of the gallbladder and is usually associated with the presence of gallstones. This inflammation can cause severe abdominal pain, nausea, vomiting, and fever. Chronic cholecystitis occurs when the gallbladder remains inflamed over a prolonged period of time, often leading to the formation of scar tissue. This condition can cause recurrent episodes of pain and discomfort, as well as digestive issues such as bloating and diarrhea.
B. Symptomatic cholelithiasis
Cholelithiasis refers to the presence of gallstones in the gallbladder. These stones can cause significant pain and discomfort, especially when they become lodged in the biliary ducts. Symptoms associated with symptomatic cholelithiasis include abdominal pain, nausea, vomiting, and jaundice. If left untreated, gallstones can cause serious complications such as cholangitis, pancreatitis, and liver damage.
C. Biliary dyskinesia
Biliary dyskinesia is a condition characterized by abnormal gallbladder motility, which can lead to the formation of gallstones and inflammation. Symptoms associated with this condition include abdominal pain, bloating, and nausea. Cholecystectomy is often recommended for patients with biliary dyskinesia who have not responded to conservative treatment.
D. Acalculous cholecystitis
Acalculous cholecystitis refers to inflammation of the gallbladder without the presence of gallstones. This condition is typically seen in critically ill patients or those with significant underlying medical conditions. Symptoms associated with acalculous cholecystitis include fever, abdominal pain, and jaundice. Cholecystectomy is often recommended for patients with acalculous cholecystitis who have not responded to conservative treatment.
E. Gallstone pancreatitis
Gallstone pancreatitis occurs when a gallstone becomes lodged in the pancreatic duct, causing inflammation and swelling of the pancreas. This condition can cause severe abdominal pain, nausea, and vomiting. If left untreated, it can lead to serious complications such as pancreatic necrosis and multiple organ failure. Cholecystectomy is often recommended for patients who have experienced an episode of gallstone pancreatitis to prevent recurrence.
F. Gallbladder masses/polyps
Gallbladder masses and polyps are often detected incidentally during imaging studies performed for other reasons. While the majority of these lesions are benign, there is a risk of malignancy in some cases. Cholecystectomy is often recommended for patients with gallbladder masses/polyps to prevent the development of cancer and to obtain a definitive diagnosis through pathology.
Cholecystectomy is a safe and effective treatment for several conditions related to the gallbladder. However, certain patients may not be suitable candidates for the procedure due to underlying medical conditions or other factors. It is essential to identify contraindications to cholecystectomy to avoid potential harm to the patient.
A. Inability to tolerate pneumoperitoneum or general anesthesia
Pneumoperitoneum is the insufflation of carbon dioxide into the abdominal cavity to create space for the surgeon to operate. General anesthesia is typically used during cholecystectomy, and both procedures can pose risks to patients who have significant cardiopulmonary or renal dysfunction. Patients who have severe respiratory or cardiac disease may not be able to tolerate pneumoperitoneum, which can cause further complications such as hypotension, tachycardia, and pneumothorax. General anesthesia may also be a challenge in patients with significant comorbidities, and alternative sedation methods may be necessary to perform the procedure safely.
B. Uncorrectable coagulopathy
Patients with bleeding disorders or on anticoagulation therapy require special consideration when undergoing surgical procedures. Coagulopathy can lead to excessive bleeding during surgery, which may prolong the procedure and increase the risk of complications such as infection or hemorrhage. While anticoagulation can be temporarily discontinued before surgery, some patients may not be able to achieve adequate hemostasis due to underlying medical conditions such as liver disease or disseminated intravascular coagulation. Such patients may be at higher risk of perioperative bleeding and would be at risk of severe bleeding complications during or after surgery. In such cases, alternative treatment options may need to be considered.
C. Metastatic disease
Patients with advanced cancer or metastatic disease may have an increased risk of morbidity and mortality after cholecystectomy. These patients are often immunocompromised, and the surgery could exacerbate their underlying condition or delay other critical treatments. In addition, patients with liver metastases or other advanced malignancies may have a higher risk of postoperative complications such as infection, hemorrhage, or bile leaks. Therefore, cholecystectomy may not be the best treatment option for patients with metastatic disease, and other palliative or supportive treatments may need to be considered.
In conclusion, cholecystectomy is an effective treatment option for several gallbladder-related conditions. However, certain patients may not be suitable candidates for the procedure due to underlying medical conditions or other factors. It is crucial to identify contraindications to cholecystectomy to avoid potential harm to the patient. The decision to perform cholecystectomy should be made on an individual basis, considering the risks and benefits of the procedure in each patient.
V. Equipment and Personnel
In order to perform a laparoscopic cholecystectomy, a team of skilled personnel and specialized equipment is required. The surgeon must have extensive training and experience in laparoscopic procedures, and must be assisted by a trained surgical team. The equipment used must be specific to laparoscopic surgery, and the staff must be well-versed in its use. In this section, we will discuss the specialized equipment and personnel necessary to perform a successful laparoscopic cholecystectomy.
A. Laparoscopic monitors and instruments
Laparoscopic cholecystectomy requires specialized equipment and instruments. The most important equipment is the laparoscope, which is a long, thin, flexible tube that has a camera and light source attached to its end. This allows the surgeon to visualize the gallbladder and surrounding structures on a video monitor. The laparoscope is usually inserted through a small incision in the umbilicus, or belly button.
In addition to the laparoscope, other specialized instruments are used to grasp and manipulate the gallbladder and surrounding structures. These instruments include laparoscopic graspers, scissors, and dissectors. They are inserted through small incisions in the abdominal wall, which are made in the right upper quadrant of the abdomen.
B. Surgeon, surgical assist, scrub tech/nurse
The laparoscopic cholecystectomy procedure is typically performed by a surgeon who has been specially trained in minimally invasive surgery. The surgeon is assisted by a team of surgical personnel, including a surgical assistant and a scrub tech/nurse.
The surgical assistant helps to hold the laparoscope and other instruments, and may assist in retracting tissues or holding the gallbladder during the procedure. The scrub tech/nurse is responsible for preparing the instruments and supplies needed for the surgery, and for ensuring that the sterile field is maintained throughout the procedure.
It is important that all members of the surgical team work together efficiently and effectively in order to minimize the risk of complications and ensure the best possible outcome for the patient. The surgeon should communicate clearly with the other members of the team and be able to rely on their expertise and experience throughout the procedure.
Surgical preparation is a crucial aspect of laparoscopic cholecystectomy. Proper preparation ensures the safety of the patient, the success of the procedure, and the prevention of any postoperative complications. Adequate preparation involves several important steps that should be followed carefully.
A. Medical optimization
Before undergoing laparoscopic cholecystectomy, the patient should be medically optimized. This involves a comprehensive medical assessment to evaluate any medical conditions that may increase the risk of surgical complications. Patients with comorbidities such as diabetes, hypertension, and heart disease should have their conditions optimized and controlled before surgery. Patients should also be assessed for any bleeding or clotting disorders to ensure that they can safely undergo surgery. If a patient is found to have a medical condition that may increase the risk of surgical complications, the surgeon may consider postponing the surgery or consulting with other specialists before proceeding.
B. Preoperative antibiotics
Antibiotic prophylaxis is an important aspect of surgical preparation. The use of prophylactic antibiotics helps to reduce the risk of surgical site infections (SSIs), which can be a significant source of morbidity and mortality in laparoscopic cholecystectomy patients. Antibiotics should be administered within one hour before surgery to ensure that adequate tissue concentrations are achieved at the time of incision. The choice of antibiotics should be based on the hospital’s antibiogram and should cover both aerobic and anaerobic organisms. In general, a single dose of a broad-spectrum antibiotic, such as cefazolin or cefuroxime, is sufficient for prophylaxis.
C. Aseptic surgical field
Maintaining an aseptic surgical field is critical in preventing postoperative infections. The operating room should be thoroughly cleaned and disinfected before surgery. Sterile drapes should be used to create a sterile field around the surgical site, and all instruments and equipment used during the surgery should be sterile. The surgeon and surgical team should perform strict hand hygiene before and after the surgery to prevent the spread of infectious organisms.
In addition to the above measures, patients should also be instructed to maintain good hygiene in the days leading up to surgery. They should be advised to bathe or shower using antiseptic soap, wear clean clothes, and avoid shaving the surgical site to prevent the introduction of bacteria into the wound.
A. Insufflation and Trocar Placement
Laparoscopic cholecystectomy begins with insufflation of the abdomen with carbon dioxide gas, creating a pneumoperitoneum to lift the abdominal wall and create a working space. The insufflation process may be performed using either an open technique, in which a Veress needle is inserted blindly into the abdominal cavity, or via a direct trocar insertion. Once the pneumoperitoneum is established, several trocars are placed through small incisions in the abdominal wall. These trocars serve as entry points for the laparoscope and other surgical instruments.
B. Gallbladder Retraction and Exposure
The gallbladder must be mobilized and retracted to provide optimal exposure for dissection. After inspecting the abdominal cavity, the gallbladder is gently grasped at the fundus with a grasper, and the infundibulum is retracted laterally to expose the hepatocystic triangle, which contains the cystic duct, cystic artery, and the common hepatic duct. Once this triangle is identified, the dissection proceeds with a critical view of safety.
C. Critical View of Safety and Dissection
The critical view of safety (CVS) is an important concept that involves dissection of the cystic duct and artery away from the common bile duct and hepatic artery, with clear visualization of the two structures. The CVS is achieved by dissection of the peritoneal layer overlying the gallbladder infundibulum, leading to the identification of the cystic duct and artery. The dissection then continues along the gallbladder bed, separating the gallbladder from the liver.
D. Clipping and Transection of Cystic Duct and Artery
Once the CVS is achieved, the cystic duct and artery are clipped and transected, completing the dissection. Careful attention should be paid to ensure that no structures other than the cystic duct and artery are clipped or damaged during the procedure.
E. Complete Separation and Removal of Gallbladder
The final step involves complete separation and removal of the gallbladder. This is achieved by dissection of the peritoneal attachments between the gallbladder and liver, followed by extraction of the gallbladder through one of the trocar sites. In some cases, a drain may be placed near the cystic bed to monitor for postoperative bleeding or bile leaks.
F. Hemostasis and Closure
Hemostasis is achieved by careful inspection of the operative field to ensure that there is no active bleeding. Once the procedure is complete, the trocar sites are closed with sutures or staples, and the skin is closed with adhesive strips or subcuticular sutures.
In summary, laparoscopic cholecystectomy is a safe and effective procedure that has revolutionized the treatment of gallbladder disease. It requires a well-trained surgical team, specialized equipment, and meticulous attention to detail to achieve optimal outcomes.
As with any surgical procedure, laparoscopic cholecystectomy carries the risk of complications. While many of these are relatively minor, there are some potential complications that can be severe and even life-threatening. In this section, we will explore the range of complications that can occur following laparoscopic cholecystectomy.
A. Common complications
Some of the most common complications associated with laparoscopic cholecystectomy include bleeding, infection, and pain. These complications are typically mild to moderate in severity and can be managed effectively with appropriate medical care. Postoperative pain is common and is usually managed with analgesics. Additionally, some patients may experience nausea, vomiting, or diarrhea following surgery, which can be treated with medications and/or dietary modifications.
B. Severe complication: injury to bile/hepatic duct
One of the most serious complications associated with laparoscopic cholecystectomy is injury to the bile duct or hepatic duct. This can occur during dissection of the cystic duct and artery, and can result in significant morbidity and mortality. Injuries to these ducts can cause bile leakage, biliary peritonitis, and sepsis. In severe cases, additional surgery or interventional radiology may be required to repair the damage.
C. Conversion to open procedure
In some cases, the laparoscopic approach may be abandoned in favor of an open procedure. This can occur if there is excessive bleeding, difficulty visualizing the anatomy, or a complication that cannot be managed laparoscopically. Conversion to an open procedure may increase the risk of postoperative complications, including infection, pain, and longer recovery times.
D. Bile leaks and management
Bile leaks are a relatively common complication following laparoscopic cholecystectomy. They can occur as a result of injury to the bile duct, incomplete sealing of the cystic duct, or inadequate closure of the gallbladder bed. Most bile leaks are managed conservatively with drainage and antibiotics, but in some cases, additional surgery may be required to repair the damage.
In conclusion, while laparoscopic cholecystectomy is generally safe and effective, it is important for patients and providers to be aware of the potential complications associated with this procedure. By understanding these risks and taking appropriate measures to prevent and manage complications, we can help to ensure the best possible outcomes for patients undergoing laparoscopic cholecystectomy.
IX. Clinical Significance
A. Etiology and Symptoms of Gallbladder Disease
Gallbladder disease is a common ailment affecting millions of people worldwide. The majority of cases are caused by the formation of gallstones within the gallbladder, a small sac-like organ located beneath the liver that stores and releases bile. Other causes of gallbladder disease include cholecystitis, biliary dyskinesia, and gallbladder polyps. Symptoms of gallbladder disease can include abdominal pain, nausea, vomiting, fever, and jaundice. In some cases, gallbladder disease can be asymptomatic, meaning the patient may not experience any symptoms at all. Gallstones can be diagnosed through various imaging tests, such as ultrasound, CT scan, and MRI.
B. Murphy’s Sign and Diagnostic Tests
Murphy’s sign is a physical exam finding that can be used to diagnose gallbladder disease. The test involves pressing on the right upper quadrant of the abdomen while the patient takes a deep breath. If the patient experiences pain or stops breathing due to the pain, this is considered a positive Murphy’s sign and may indicate gallbladder disease. Other diagnostic tests for gallbladder disease include blood tests to assess liver function, endoscopic retrograde cholangiopancreatography (ERCP) to visualize the biliary tract, and a HIDA scan to assess gallbladder function.
C. Non-Surgical Management of Asymptomatic Patients
Asymptomatic gallstones are a common finding on imaging studies, especially in patients over the age of 40. In these cases, the decision to proceed with surgery depends on various factors, including the size and number of stones, the patient’s age and overall health, and the presence of other medical conditions. In some cases, asymptomatic gallstones may be monitored over time with regular imaging studies and treated only if symptoms develop. Non-surgical management of gallbladder disease includes lifestyle modifications such as dietary changes and weight loss, as well as medications to dissolve or prevent the formation of gallstones.
X. Interprofessional Team Collaboration
A. Importance of Communication and Collaboration
The management of gallbladder disease requires a collaborative approach among various healthcare professionals, including primary care providers, gastroenterologists, radiologists, and surgeons. Effective communication and collaboration among team members are essential for ensuring optimal patient outcomes. Preoperative optimization of medical conditions, appropriate imaging studies, and accurate diagnosis of gallbladder disease all rely on effective communication among team members.
B. Improving Patient Outcomes
Improving patient outcomes in the management of gallbladder disease requires a multidisciplinary approach that includes patient education, shared decision-making, and follow-up care. Patients should be informed of the risks and benefits of surgery, as well as the potential complications associated with gallbladder disease. Shared decision-making between the patient and healthcare team can help to ensure that the best treatment plan is selected based on the patient’s individual needs and preferences. Finally, follow-up care after surgery or non-surgical management of gallbladder disease is crucial for monitoring the patient’s progress and ensuring optimal long-term outcomes.
A. Summary of Key Points
In this paper, we have provided an overview of laparoscopic cholecystectomy, a commonly performed surgical procedure for the treatment of gallbladder disease. We discussed the anatomy and physiology of the gallbladder, indications and contraindications for the procedure, equipment and personnel required, preparation, surgical technique, potential complications, clinical significance, and interprofessional team collaboration.
B. Future Directions for Research and Practice
While laparoscopic cholecystectomy is a safe and effective procedure, there is always room for improvement. Future research should focus on identifying ways to further reduce complications and improve patient outcomes. For example, new technologies or techniques for better identifying and preserving critical structures during the procedure could be developed. Additionally, studies could explore the use of non-invasive or less invasive treatments for gallbladder disease, potentially reducing the need for surgical intervention.
Furthermore, interprofessional team collaboration and communication are critical for ensuring optimal patient care. As such, healthcare organizations should continue to prioritize team-building and communication training for healthcare providers. By doing so, patients will receive the highest level of care and experience better outcomes.
In conclusion, laparoscopic cholecystectomy remains a widely accepted and effective surgical intervention for gallbladder disease. By following the proper indications and techniques, and by prioritizing effective interprofessional team collaboration, this procedure will continue to be an important component of patient care.
- Ahmadi N, Sistani R, Ghorbani A, et al. Intraoperative cholangiography during laparoscopic cholecystectomy: a review of 13 years’ experience. Wideochir Inne Tech Maloinwazyjne. 2018;13(4):453-459. doi:10.5114/wiitm.2018.78591
- American College of Surgeons. (2021). ACS NSQIP Participant Use Data File.
- American College of Surgeons. (2021). ACS NSQIP Surgical Risk Calculator.
- Borzellino G, Sauerland S, Minicozzi AM, Verlato G, Di Pietrantonj C, De Manzoni G, Cordiano C. Laparoscopic cholecystectomy for severe acute cholecystitis in elderly patients. Surg Endosc. 2006;20(10):1586-1591. doi:10.1007/s00464-005-0701-1
- Koo KP, Traverso LW. Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy? Am J Surg. 1996;171(5):495-499. doi:10.1016/s0002-9610(99)80026-4
- Li X, Zhang X, Liu D, et al. Laparoscopic versus open cholecystectomy for elderly patients: a systematic review and meta-analysis. BMC Surg. 2019;19(1):54. Published 2019 May 23. doi:10.1186/s12893-019-0521-y
- Singh K, Ohri A. Perioperative management of laparoscopic cholecystectomy: A systematic review. J Minim Access Surg. 2019;15(3):193-202. doi:10.4103/jmas.JMAS_79_18
- Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9(5):543-547. doi:10.1007/s005340200073
- Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101-125.
- Tinoco R, Tinoco A, El-Kadre L, et al. Laparoscopic cholecystectomy in acute cholecystitis: a systematic review. Arq Bras Cir Dig. 2017;30(4):282-286. doi:10.1590/0102-67202017000400012
- Habib, F. A., Al-Momen, S. A., & Gelaidan, A. T. (2000). Laparoscopic cholecystectomy: A retrospective study of 295 cases. Saudi Medical Journal, 21(5), 464-467.
- Soper, N. J. (2003). Complications of laparoscopic cholecystectomy. American Journal of Surgery, 165(5), 527-535.
- Khajanchee, Y. S., & Hansen, P. D. (2006). Understanding complications of laparoscopic cholecystectomy: a multimodality approach. Journal of Surgical Education, 63(5), 337-346.
- Hassani, Z., & Yegane, R. A. (2010). Comparison of ultrasonic and electrocautery dissection in laparoscopic cholecystectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques, 20(6), 479-482.
- van der Linden, Y. M., Brenninkmeijer, S. J., & Schreurs, W. H. (2014). Risk factors for conversion during laparoscopic cholecystectomy–experiences from a general teaching hospital. Scandinavian Journal of Surgery, 103(3), 180-186.
- Bessa Jr, L. J., de Menezes, M. R., & Ribeiro Jr, U. (2016). Laparoscopic cholecystectomy: intraoperative cholangiography versus no cholangiography in the prevention of bile duct injury-Systematic Review and Meta-Analysis. Arquivos brasileiros de cirurgia digestiva, 29(2), 130-135.
- Okamoto, K., Suzuki, K., Takada, T., Strasberg, S. M., Asbun, H. J., Endo, I., … & Yokoe, M. (2018). Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences, 25(1), 55-72.
- Song, X., Liu, Y., Kong, L., & Guo, Y. (2019). Comparison of clinical efficacy between laparoscopic cholecystectomy and open cholecystectomy for acute cholecystitis: a systematic review and meta-analysis. International Journal of Surgery, 70, 71-81.
- Yoon, J. H., Lee, J. H., Kim, J. H., Lee, S. H., & Kim, S. H. (2020). Preoperative predictive factors of conversion to open cholecystectomy in acute cholecystitis. Annals of Surgical Treatment and Research, 99(6), 308-314.
- Shrestha, D., Singh, D., & Gautam, N. (2021). Comparison of intra-operative versus post-operative administration of antibiotics in patients undergoing laparoscopic cholecystectomy. Journal of Nepal Health Research Council, 19(3), 588-592.