The edition · General Surgery
ICG cholangiography was linked to fewer bile duct injuries across 1.27 million cholecystectomies
A weighted US cohort found lower bile duct injury and conversion rates when fluorescence cholangiography was used. Plus which gallbladders may justify the robot, what the robotic hernia evidence can and cannot show, and a sex and age gradient in survival after traumatic shock.
The edition in brief
In 1,266,024 US laparoscopic cholecystectomies from 2016 to 2024, intraoperative indocyanine green fluorescence cholangiography, used in 13%, was associated with fewer common bile duct injuries (0.25% vs 0.40%, RR 0.62) and half the conversion rate after weighting for confounding. It is observational. A multihospital study of 1,828 cholecystectomies by surgeons doing both approaches found robotic surgery associated with fewer conversions or major complications overall (3.3% vs 8.7%), concentrated in difficult gallbladders and higher BMI, at about US$2,200 to $2,400 more per case. A SAGES meta-analysis of robotic ventral hernia techniques found lower complication rates and shorter stays for some robotic approaches but longer operating times, from mostly high-risk-of-bias studies. In 109,819 US patients with severe injury and shock, women had lower in-hospital mortality (aOR 0.86), with the largest gap at 55 and over, a pattern the authors say does not fit a simple oestrogen explanation.
Robotic cholecystectomy was linked to fewer adverse outcomes in difficult gallbladders
Reserve the robotic approach, where available, for difficult gallbladders in patients with higher BMI; laparoscopy did as well elsewhere at lower cost.
Robotic ventral hernia repair: fewer complications in some comparisons, longer operations
Consider the robot mainly for complex repairs that would otherwise be open; for simple intraperitoneal mesh repair, the case for it is weak.
Women survived traumatic shock more often, most clearly after 55
Do not change resuscitation by sex; note that older men with traumatic shock had the worst survival in this registry.
No critical view, no clip: know your bailout
Clip nothing until the critical view of safety is achieved, and use a bailout when it cannot be.
ICG cholangiography linked to fewer bile duct injuries in 1.27 million cholecystectomies
Where fluorescence equipment exists, consider ICG cholangiography routinely in laparoscopic cholecystectomy, always alongside the critical view of safety.
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