THE VASILE GOLDIȘ WESTERN UNIVERSITY OF ARAD [614258]

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THE “ VASILE GOLDIȘ” WESTERN UNIVERSITY OF ARAD
THE FACULTY OF GENERAL MEDICINE IN ENGLISH

BACHELOR THESIS

SCIENTIFIC SUPERVISOR
Lect. Univ. Dr. Papiu Horațiu
GRADUATE
Dr. Edoardo Giannotta

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THE “ VASILE GOLDIȘ” WESTERN UNIVERSITY OF ARAD
THE FACULTY OF GENERAL MEDICINE IN ENGLISH

Consideration s on the
surgical procedure in acute
lithiasic colecy stithis

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INDEX

Introduction ………………………………………………………………………………………………………….4
1.1 General Part ……………………………………………………………………………………..5 -8
1.1.1 Gallbladder positi oning and anatomy……………………………………………5 -7
1.1.2 Physiology ……………………………………………………………………………..7
1.1.3 Para -Clinical signs …………………………………………………………………..7
1.1.4 Clinical Investigations ………………………………………………………………8
1.2 Summary of the technique of VLC intervention…………………………………………….8 -13
1.2.1 Generality…………………………………………………………………………….8
1.2.2 Preparation of the access…………………………………………………..……..8 -9
1.2.3 Isolation of structures in Calot triangle and the procedure………………….9 -12
1.2.4 Dissection of Gallbladder from liver bed …………………………………………12
1.2.5 Extraction of Gallbladder ………………………………………………………….12
1.2.6 Final maneuvers ……………………………………………………………………..13
1.3 Summary of the technique of cholangiography with VLC ……………………………….14 -16
1.3.1 Generality ……………………………………………………………………………14
1.3.2 Preparation of the access ………………………… ………………………………..14
1.3.3 Isolation of structures in Calot triangle ………………………………………14 -16
1.4 Injuries of the abdominal wall……………………………………………………………… 16 -18
1.4.1 Incisional hernias ………………………………………………………………..16 -17
1.4.2 The parietal bleeding …………………………………………………………..1 7-18
1.5 The Nerve Damage……………………………………………………………………………….18
1.6 Neoplastic recurrence on the Abdominal Wall………………………………………………….18 -19
1.7 Vascular Injuries…………………………………………………………………………….……20
1.7.1 The large vessel injury …………………………… ………………………..……….20
1.8 Iatrogenic injuries of the bowel ……………………………………………………….……20 -21
1.8.1 The lesions of the duodenum ………………………………………………………..30
1.8.2 The lesions of the small intestine, colon and other organs ……………..20 -21
1.9 Iatrogenic injuries of the biliary tract …………… …………………………………………21 -22
1.9.1 The epathic injury and bile duct ……………………………………………………21
1.9.2 The Mirizzi syndrome ……………………………………………………………21 -22
1.10 Bile spill………………………………………………………………………………….…..22 -23
1.10.1 The dislocations of the clips ………………………………………………….… …22
1.10.2 Lithiasis on a foreign body ………………………………………………………….23
1.11 Complication liked to the perforation of the gallbladder and the lithiasic spill ….…23 -24
• Abscess of the wall
1.11 Imagining methods…………………………………………………………………………….24
2.1 Special part………………………………………… ………………………………………….….25
Aim and motivation of the study ……………………………………………………………25
2.2 Material and methods……………………………………………………………………………..26
2.3 Results………………………………………………………………………………………………27
2.3.1 Gender…………………………………………………………………………………..27
2.3.2 Age o f the patients……………………………………………………………….28 -29

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2.3.3 Operator approaches and conversions …………………………………………..…30
2.3.4 Dimension of the gallstones……………………………………………………….31 -32
2.3.5 Acute or Chronic Acutized………………………………………………………..33 -34
2.3.6 Assoc iation wit h adherence syndrome (with \without)……………….……35 -36
 Men……………………………………………………………………….…35
 Women ………………………………………………………………………36
2.3.7 Associated Pathologies ………………………………………………………..37
2.3.8 I ntra operative incidence and complication (accidents) …………………..….38
2.4 Disc ussion……………………………………………………………………….………39
2.4.1 Gender…………………………………………………………………………………..39
2.4.2 Age of the patients……………………………………………………………………..40
2.4.3 Operator approaches and conversions ………………..……………………………41
2.4.4 Dimension of the gallstones………………………………… ………………………..41
2.4.5 Acute or Chronic Acutized……………………………………………………..…41 -42
2.4.6 Assoc iation with adherence syndrome (with \without)………………….…42 -43
2.3.7 Associated Pathologies ………………………………………………………..44
2.3.8 I ntra operative incidence and complication (accid ents) ………………………44
2.5 Conclusions………………………………………………………………………….45 -46
2.6 Bibliography………………………………………………………………………….46 -47

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Introduction
The gall bladder stones are small solid agglomerates that consist mainly of cholesterol and calcium
salts. Often they do not cause any symptoms and do not requ ire any treatment (asymptomatic ); other
times they move from their original locations, blocking the bile flow and causing a condition known
as acute cholecystitis (biliary colic), accompanied by inte nse, intermittent abdominal pain . About
15% of the adult population in each country is suffering from gallstones, with a higher prevalence in
old women; the difference between the sexes tends to flattening , increasing the age . It is a common
problem and of ten surgery is performed as a preventive measure .
The purpose on this work is to analyze all the aspect of this procedure, and evaluate its pros and cons .

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General Part

1.1.1 Gallbladder positioning and anatomy
The gallbladder is a pear-shaped, hollow
viscus that connected to the extrahepatic biliary
tree by the cystic duct. There is considerable
variations in dimension; approximate length and
diameter of the fully distended gallbladder are
10 and 4 cm, respectively. The gallbladder ’s
capacity is up to 45ml.1
The gallbladder is divided in three parts:
 The Fundus forms the antero -inferior
margin with his hemispherical ending
 The neck connects to the cys tic duct and
define the postero -superior limit
 The lumen is the widest at the junc tion of the body and the fundus tighten towards the neck ;

The gallbladder is located in a concavity of the inferior surface of the liver called “the gallbladder
fossa” and generally marks the caudal limit of the interlobar fissure .
The variability with which the cystic duct fits on t he principle bile duct is consider able, even though ,
some of the most frequent insertion method are recognizable.

– – – – – – – – – – – –

Position of the gallbladder

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The cystic duct can (image 1) :
1. run parallel to the biliary tract for a tract more or
less long
2. cross on front the principal bile duct with an outlet
on the left
3. cross on behind the principal bile duct with an
outlet on the left
4. have a short course with hypertrophic or atrophic
gallbladder
5. have a short course wit h melted gallbladder neck
with the principal bile duct
6. have a long course with on outlet in the low biliary
tract or in the papilla
The gallbladder is sprayed by the Cystic artery originated from the right hepatic artery and move to
the organ’s neck passin g both sides of the cyst ic duct; on the lower face origin ate a right and a left
branch running on the sides of the lower face of the body. The veins get tog ether in a common trunk
tributary of the right branch of the portal vein; the most numerous are br ought directly from the
gallbladder wall in the liver parenchyma (accessory port veins). [7]
Also, the course of cystic artery has many anatomical variants; the artery can:
1. Originate from the right hepatic artery and cross the bile duct at the rear (70%)
2. Originate from the left hepatic arter y and cross the bile duct on the front (20%)
3. Originate from the gastroduodena l artery and cross the bile on the front (2%)
4. Originate from the gastr oduodenal artery, cross and run on the rear of the gallbladder to the
bottom and, from there, towards the neck
5. All the above can be comb ined and show intermediate case

Lymph gather in three or four main trunks; they flock to :
1. lymph node of the cystic
2. Morgagni ’s lymph node
3. Superior p ancreatic -duodenal lymph nodes
4. Posterior panc reatic -duodenal lymph nodes
5. common hepatic duct
6. Choledochus duct

Image 1 anomalies of the bile duct [24]

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These structures define major topographical areas for the surgeon including (image 2) :
• Epato-cistic triangle , formed by the gallbladder and the
cystic duct on the right, common hepatic duct on the left
and he patic margin superiorly
• Calot t riangle, a portion of the previous , bounded by the
same lateral and medial structures, but with the top
margin rep resented by cystic artery
• Moosman area , defined by a circumference of about 30
mm in diame ter, centered on the corner of the common
hepatic duct and cystic duct. [8]

1.1.2 Physiology
Bile from the hepatocytes is stored and concentrated in the gallbladder and ultimately ejected into
the gastrointestinal (GI) tract, under the influence of the parasymp athetic nervous system and
circulating hormones:
a. Cholecystokinin: is a molecule that promotes the secretion of pancreatic hormones and the
contraction / emptying of the gallbladder.
b. Secretin: promotes an increase in volume and concentration of bicarbonate that results in a
greater flow of bile fluid, an increase PH and bile osmolality favoring its outflow.
c. Gastrin: regulates the release of hydrochloric acid in the stomach
d. VIP (Vasoactive Intestinal Peptide): Cholecystokinin antagonist
e. PP (Polypeptide Panc reatic): determinate a release from the gallbladder
f. Somatostatin: Inhibits all pancreatic and gastrointestinal secretions

1.1.3 Para -clinical signs
Symptoms (Segni e sintomi della medicina d'urgenza Di S. R. Votey,M. A. Davis)
Acute pain in the upper ri ght quadrant or epigastric pain.
nausea and vomit
Sometimes fever
Signs
Localized peritonitis
Murphy sign

Image 2
Epatocistic triangle (red)
Calot triangle (blue)
Moosman area (pointy)
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1.1.4 C linical investigation
Laboratory examinations :
VES,
comple te emocromium, (Alfa 2 globulin salt )
bilirubinemia,
transaminases,
cholesterol emy,
Instrumental investigations:
hepatocellular ultrasound
colic and cologne radiography,
TAC and nuclear magnetic resonance imaging

1.2 Summary of the technique of VLC intervention
1.2.1 Generality
The surgery is performed under general anesthesia wi th the aid of an oximeter an d a
capnometer in order to quickly balance and prevent possible variations in PCO2 resulting from the
absorption of CO2 from the abdominal cavity, where the pneumoperitoneum is induced , by blowing
approximately 2 – 4 liters of C O2 up to a pressure of 10 -14 mm Hg to allow th e abdominal distension.
A nasogastric tube is placed , which will be removed at the end of the intervention, in order to relax
the stomach.
The patient is in supine position with lower limbs abducted , between wh ich is placed the first
operator. The second and the third operator are arranged to the sides of the operating table. [3]
1.2.2 Preparation of the access
The induction of pneumoperitoneum is carried out via the Veress needle that is perpendicular ly
introduced through a right periumbilical incision . Another "open" mode is with Hanson cannula.
Image 3
Position of the trocars
http://www.pavlos -lagoussis.com

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The operation begins with the induction of pne umoperitoneum. T hen proceeds to the introduction of
the troca r according to the diagram (image 3) :
In the diagram are s hown in the order of introduction the four access sites in the peritoneal
cavity: (1) umbi lical, (2) under the left costal arch, (3) between the right mid -clavicular and umbilical
transverse, (4) between the left mid -clavicular and umbilical transverse.
The first , with a diameter of 10 mm, through the same umbilical incision. Throug h this trocar
the optical system connected to the camera is passed . From now on, unde r careful visual inspection,
are introduced the other trocars ;
The se cond , inserted on the apophyses ensiforme ’s left, 2 cm below the costal arch, for the
introduction of the aspirator / irrigator. This tool is also used to lift t he liver and the round ligament,
The third trocar inserted to the right, at th e intersection of the umbilical transvers e and the
right mid-clavicular line ; allows the use of a clamp to stretch the infundibulum of the gallbladder and
better highlight the vascular and bil iary elements of Calot triangle.
The fourth trocar , placed to the left, at the intersection between the l eft mid -clavicular line
and the umbilical transverse, allows the introduction of all the tools necessary to perform the
cholecystectomy (laser probe and / or dissector with associated electric scalpels, scissors, pliers pose
clips, etc. ).

1.2.3 Isolation of structures in Calot triangle and the procedure [3]
The operation continues with the incision of the peritoneum covering the inf undibulum and
the cystic duct up to completely isolate the latter and to render the entire circumference well visible.
In the diagram (image 5 ) it is shown how, while with the grasper is underlay the gallbladder, the
dissector and the palpatoresis opens the peritoneum and isolate the cystic and cystic artery .
Imag e 5

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.

The procedure could begin with the lysis of adhesion s, result o f inflammatory processes that
often cover the gallbladder (image 6)

The peritoneum coverin g the infundibulum and cystic are opened and i s isolated the cystic
that is subtend ed by the stylus while with the dissector is isolated the c ystic artery. (Image 7 )
Image 6
Begin of the procedure (see lysis)
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Image 7
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Four clips on the cystic are visible (image8)

The cyst ic is cut with scissors between the clips. (Image 9)

Image 8
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Image 10
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The cyst ic is dissecte d (image10) between the clips and is visib le the proximal stump ( arrow
1). Similarly also the cystic artery was sectioned between two series of clips (arrow 2).
Is positioned, therefore, a titanium clip close to infundibulum and two more clips at about 5 mm from
the first in the direction of the common bile duct (CBD). Subsequently the surgeon ident ifies the
cystic artery and make hemostasis with metal clips. [3]

1.2.4 Dissection of Gallbladder from liver bed
Completely sectioned the biliary -vascular pedicle , it proceed s with the dissection of the gallbladder
from the liver bed.

The gallbladder was completely detached from the liver bed checking the hemostasis. (Image 11 )
At this stage, a complete hemostasis of the hepatic bed is nec essary , check ing carefully after
repeated washing and aspiration.
(The as piration of the fumes produced by the electric scalp el or laser may represent a transitory
problem for those nearby the operating field .)

1.2.5 Extraction of Gallbladder
The gallbladder, now dissected, is placed temp orarily on the right lobe of the liver and is
extracted through the trocar placed in the umbilical breach. If the gallbladder is lying or gallstones of
large dimensions the 10 mm umbilical trocar is replaced with one of a larger diameter (20 mm Kleiber
trocar ) in order to avoid the need to empt y the gallbladder and therefore , the contami nation of the
peritoneal cavity (image 12 ).
Imag e 11
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If the gallbladder is distended by
numerous gallstones larger than 20
mm, it could be brought directly under
the umbilical breach and carefully
extracted with traction/ rotation mixed
movements . In some cases, may be
necessary to expand the umbilical
breach of one or two centimeters.
Then the optics is moved in the left
umbilical trocar in order to control the
phases of extraction of the gallbladder. In case of “check” interventions for the inflammation of the
tissues , is positioned a sub-hepatic drainage. Some operators always put a drainage, to keep for 12 –
24 hours, in order to allow the complete elimination of the pneumoperitoneum, which can be the
cause of pains rad iated to the back and shoulders (image 13)

1.2.6 Final maneuvers
The tools are extracted; the four trocars are removed and the small surgical wounds are
sutured , closing also, the F ascia (muscular bundle) and this especially if used a 20 mm t rocar.

Image 12
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Image 13
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1.3 Summary of the technique of cholangiography with VLC

1.3.1 Generality
They are completely similar to those described for VLC.
The patient is supine with legs adduct ed, on a radiolucent operating table. The first operator is on the
left.

1.3.2 Preparation of the access
Almost i dentica l to that described for the VLC but a fifth right subcostal access is necessary
to introduce the cholangiographic catheter. This access can also be very small (14 -16G needle of a
centr al subclavian venous access kit).

1.3.3 Isolation of the structures in Calot triangle
Identical to that described for the VLC.
A clip is positioned near the infundibulum and the cystic is partially dissected with scissors .
After follow the insert ion of the cholangiography catheter into the cystic. If there is not a specific kit
for intr aoperative VL cholangiography, can be used a subclavian venous catheter with Seldinger
guide (image 15 ). In this case , the intr oduction can be easier if you do not draw back the guide wire.
Eliminate all air bubbles from the catheter is extremely important. T he injection of iodin ated contrast
and the recovery of radiograms is the last step . Retired the catheter , the cystic stump is closed with
two clips and it is totally dissected .
The catheter, ver y flexible, is made
more rigid by leaving inside the
Seldinger guide . The arrow point the
cystic (image 14 ).This technique is
generally used in everyday clinical
practice.

Image 14
A subclavian venous catheter is used
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The semi -rigid catheter, at an angle of about 90 °, required to reach t he cyst. (Image 16 )

A clamp with soft grip secures the gap between the cystic and the catheter . (Image 17 )

Image 16
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Image 17
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After performing the radiographic examination, the cystic is closed with a metal clip while the semi
rigid catheter is removed. [3]

1.4 Injuries of the abdominal wall
1.4.1 Incisional hernias [4]
In conv entional “open ” surgery after months or years , hernias appear on the laparotomy wound.
Factors predisposing to the formation of these hernias are:
1. wound infection;
2. the use o f inadequate suture materials: diameter, porosity and resorption time;
3. inadequate surgical technique;
4. certain diseases of the patient who requi re strong medications (cortisone, chemotherapy,…)
in the immediate postoperative period;
5. Chronic bronchitis with cough (smoking with abundant br onchial secretion and cough …);
6. Obesity.
The video -laparoscopic surgical techniques have emerged precisely because they are more respectful
of the patient (patient -friendly surgery) ; doctors and patients all have immediately a greed that most
of the pain and complications of minor and medium interventions originate from the abdominal wall .
For this reaso n, the possibility of having wall complications see med immediately as "impossible”.
The reality is that the presence of hernia l complications is in the order of 0. 2% in most series. This
very low value means , however, that patients n eed to be followed in search of this complication.
The site where more frequently postoperative hernia should be noted is the one through whic h
was ex tracted the gallbladder, this for the following reasons:
Image 18
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1. The gallbladder may contains gallstones with size even higher than 3 -4 cm and this requires
to expand the g ap through which passed the trocar (usually 10 mm) to allo w the passage of
the gallstone. In some cases, the 10 mm trocar is replaced with a 20 mm trocar (Kleiber), but
in some situa tions to extract the gallstone must be practice d a mini -laparotomy;
2. The gallbladder may contain infected bile that contaminates the wound;
3. Suturing of the breach is a ll the more uncomfortable the more it is small especially in
overweight patients.
To these reasons already lis ted for open surgery, we have to add some specific aspects of video –
laparoscopic technique:
1. During the extraction of the trocars the abdominal con tents is pushed by the residue
pneumoperitoneum in the direction of the breach in the wall and there remains “stuck” due to
the pressure;
2. if the trocar’s valve is not open, the cannula itself may exert an aspiration (suction cup effect)
on the abdominal co ntents dragging till near the wall;
3. the muscle relaxation, often modest or completely absent in the terminal stages of the
interventions, hel ps to "fix" the omentum or handles (organic tissue that folds back on itself )
that have come in contact with the abdominal wall.
Not all operators suture the fascial gaps. Almost everyone agrees that the breaches result from
5mm instru ments do not require sutures unlike those from 20 mm , but for those from 10 mm opinions
are divided . [4]

1.4.2 The parietal bleeding [9]
The abdominal wall is richly vascularized by small diameter vessels that o riginate at the top
and front from the intercostal thoracic branches and inferiorly from the lumbar and hypogastric
branches . The flow of these ve ssels is modest, but if an accurat e hemostasis is not pract iced, can also
cause massive bleeding. Even the wall of the muscle can be a source of bleeding.
Generally, the bleeding is limited to the thickness of the sheet of the wall with the formation of a
hematoma. In other cases, the hema toma makes its way between the parietal layer of the peritoneum
and the muscle -fascial ou ter layer with possible rupture later. Much more rarely the bleeding occurs
in the peritoneum, even with the formation of collections of several tens of ml.
Thes e hemo rrhages are sneaky in formation: d uring the operation are covered by the
presence itself the trocar’s cannula and the backpressure of pneumoperitoneum . When the
pneum operitoneum and the trocar’s cannula are removed , the vessel is in a state of spasm and th e

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bleeding may be minimal or even absent. In the hours after the resolution of t he vascular spasm, the
bleeding can appear . [9]

1.5 The nerve damage [2]
The frequency of damage s to the nerve trunks that innervate the wall is not known in literature
and ar e reported individu al cases. In the presence of a nervous damage is useful to conduct a
differential diagnosis with:

In particular, regarding cholecystectomy, we consider the right subcostal, para-rectal, right,
and median trans -rectal accesses . Except the median access, surely the most "inconvenient" for the
surgeon, all the others have in common the risk of d amaging the nerves that provide the tropism of
the muscles masses of the abdominal wall. The trunks that innervate the abdominal wall are the
following:
 n. intercostal T5 – T11
 n. under -costal T12
 n. ileum -ipogastric T12 – L1
The course of all these tr unks is oblique from top to bottom and therefore a too deep vertical a ccess ,
exposes to iatrogenic injury; if you need to expand the access, it is preferable rather d o a horizontal
incision. [2]

1.6 Neoplastic recurrence on the abdominal wall
The neoplast ic facility [1]/ [11]
The number of cholecystectomies for the treatment of cholelithiasis increased since when was
introduced in 1987; going from a percentage of about 29% before the introduction to the situation
nowadays in which the classic “open” surger y is used just in extreme cases .
At the same time, there has been an increase in reported c ases of gallbladder carcinoma
passing from 0. 28% in the “ open ” era to the actual 0.6% . This situation is common to almost all
international case studies and show onl y minor regional variations. Damage to nerve trunks Frequently after lobotomy
Neuropathy Diabetes
Herpes Zoster
Nerves compressions Herniated disk
Retroperitoneal tum or

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The increase in gallbladder cancer seems to be only apparent if consider ed that the diagnostic
tools are unchanged, mainly ultrasound and Computerized Axial Tomography , and increase only in
cases with a gallbladder removed for other reasons (essentially for a cholelithiasis). The problem is
that the random finding o f a gallbladder malignancy during VLC preclude a therapy according to the
canons of conventional open surgery and it seems that is accompanied by a large numbe r of
intraperitoneal and along the route of the port recurrences. These recurrences seem unrelated to the
manipulation of the tumor or to the surgical technique, but rather to specific yet unknown aspects of
laparoscopic procedures . [1]
It follows that it is very necessary to look for new diagnostic tools that have greater sensitivity
and specificity for this type of disease in order to reduce the number of cancers of the gallbladder
incidentally retrieved. At the same time, it is necessary to identify the risk fa ctors that lead to exclude
from VL technique pati ents with a suspicion of gallbladder carcinoma.
These criteria currently appear to be the following:
1. porcelain gallbladder wall or also only focally calcified (img. 19 )
2. patient age> 70th;
3. clinical history of cholelithiasis, even asymptomatic, longstanding;
4. presence of gallbladder polyps (if the polyp has a size> 15 mm accommodates a neoplasm in
45% of cases);
5. Thickened gallbladder wall even only locally.
These criteria could indicate to perform a histolog ical examination to confirm a diagnosis that could
lead to a more radical oncological intervention , if the age o f the patient, the risks of the intervention
and his life expectation make it possible.
The palpation of the gallbladd er, which in the “open” inte rvention allows the surgeon to have
an idea, even if partial, of the disease is not possible with VL technique except for a mediated
palpation that does not allow any assumptions. [11]

Image 19
Porcelain gallbladder
(Calcification of the wall of the
gallbladder ). Ultrasound view of
the gallbladder [21]

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1.7 Vascular injuries
1.7.1 The large vessel injury [12]
Vasc ular lesions are extremely rare, but their severity can be devastating. Their gravity is such
as to constitute the second leading cause of death during surgery in laparoscopy (t he first cause are
the anesthetic complications).
Some reviews [18], involving more t han 100,000 interventions in VL, have shown that the
percent age of vascular lesions amount to 0, 1 – 0, 25% with a mortality of 8.8% approximately. In the
case of vascular injury to the triangle of Calot (portal vein and branches, hepatic artery and branches )
the mortality drops to 4.1 %. The majority of the lesions usually occur in the early stages of the
intervention during the induction of pneumoperitoneum with a Veress needle and due to the blind
introduction of the 1 ° trocar.

1.8 Iatrogenic inju ries of the bowel

1.8.1 The lesions of the duodenum [14]
The duodenum injuries are very rare. However, emerge a small percentage of lesion of
duodenum in the order of 0.2% that is comparable to iatrogenic lesions of the biliary tract. From an
anatomical p oint of view, the duodenum lesions may involve the up per, lower knee and the posterior
portion of the duodenum (retroperitoneal ).
The pathogenesis of these injuries can be attributed to the following causes:
• presence of strong adhesions that modify the anatomy anchoring the antral -pyloric -duodenal
complex to the gallbladder;
• the use of an inadequate instrument (sharp and sharp dissectors, pointed feelers, … );
• the use of monopolar dissectors with consequent electro -thermal damage even at a distance
and witho ut direct contact .[14]

1.8.2 The lesions of the small intestine, colon and other organs
The pathogenesis of these injuries can be attributed to the following causes:
• Presence of adhesions, not necessa rily tenacious, but also weak , which adhere the intesti ne to
the abdominal wall and / or other viscera;
• The use of “closed ” techniques for the introduction of the first port (pneumoperitoneum with
Veress needle or Hasson cannula).
Typically when introducing the camera there will be immediate cognition of the l esion as it sees
bubbling the intestinal contents mixed with gas ; sometimes the pressure of pneumoperitoneum can

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mask the spot, however, the enteric mucosa fungus is appreciated . In other cases, there is no
evidences . From a clinical point of view, the ent eric mate rial causes an immediate peritoneal reaction
like in peritonitis .

1.9 Iatrogenic injuries of the biliary tract
1.9.1 The injury of liver and bile duct
The injury of the common liver , the right epathic branch , and common bile duct are extremely
serious. The lesion is usually caused by a partial dissection of the elements to the Calot triangle with
a consequent incorrec t assessment of the relation between hepatic duct, cystic duct and common bile
duct.
To avoid injury of the bile duct is necessary to be extremely cautious a nd may be useful:
• isolate the elements of the triangle of Calot by pulling laterally the gallbladder on the
infundibulum,
• open two windows, one for the cystic and one for the cystic artery, and not dissect the duct
until it is no t clarified the anatomy of the region;
• Intraoperative cholangiography may help to clarify the situation;
• retrograd e dissection of the gallbladder, if possible , after artery dissection between clips;
• Don’t try the dissection of a Calot triangle if appears a ppear deformed by fibrotic tissue,
edema and inflammation;
• Accept a conversion "more" rather than a lesion of the bile duct. [5]

1.9.2 The Mirizzi syndrome [10]
From the anatomic -pathological point of view the syndrome is chara cterized by the presence
of wedg ed gallstone s in the infundibular region ( in the Hartmann's pocket ) or in the distal cystic in
proximity of the hepatic duct common with the common bile duct junction with the presence of a
dense tissu e scar caused by a “sleepy” inflammation. It can be clinically accompanied by compression
of the lithiasic formations on the bile duct with obstructive jaundice.
Two forms are classified:

type 1 External compression of the common hepatic duct by a wedged
gallstone (cystic , pocket Hartmann, infundibulum) w ith eventual
fusion of the cystic and consequent obliteration of the triangle of Calot
type 2 the presence of a fistula between the gallbladder and bile duct

23
The inflammation and the resulting anatomical change combined with the brevity of the cystic
or in some cases even his complete absence, implies that the risk of damaging the main bile duct is
extremely high. The risk i s so high that a VLC is absolutely contraindicate in case the Mirizzi
syndrome if identified preoperatively.
The preoperative diagno sis is made, most of the times, by ultrasound (15 -20% of cases), but
only the percutaneous cholangiography can provide certain images of a fistula between the bile duct
and gallbladder. The incidence of the syndrome fluctuates between 0.05% and 1%, while t he
percentage of conversion of a VLC intervention to open one is 70% for the syndrome type 1 and
100% in type 2. [10]

1.10 Bile spill
1.10.1 The dislocations of clips [15]
The postoperative clinical symptomatology that leads to the suspicion of a lesion o f the bile
duct is characterized by cholestasis, jaundice, and sepsis all to be put in relation with also the septic
bile peritonitis .
One o f the most frequent causes, and luckily the one with the easiest treatment , is the loss of
bile from the cystic stum p. Usually, during VLC, the cyst is cut between clips making sure to leave
at least two clips on the stump.
The causes of displacemen t of the clips are not clear; but pay the most attention to the
positioning of the clips , which must be parallel to each ot her, and to the method of section of the
cystic can be helpful . The cystic must be dissected leaving a few millimeters margin of tissue beyond
the edge of the last clip and the section must be practiced with scissors rather than with the monopolar
coagulat or because it generates a large amounts of heat that damage the. The treatment of biliary
fistulas supplied by the cystic can be very simple: it is to decompress the bile duct with a drain to
keep for at least 7 -14 days. The drainage follows a diagnostic ERCP that has the purpose to exclude
the presence of an iatrogenic lesion of the bile duct.
In conclusion to avoid bile leaks from the clips dislocation, it is imperative to implement the following
measures:
• position the clips (at least 2) parallel to each other
• dissect the cystic using scissors and not the monopolar dissector to prevent the possible
formation of scars
• leaving a portion of the cystic a few millimeters beyond the edge of the last clip
• If there is concern about the tightness of the clips, use only of different size or a different
manufacturer; alternativel y bind the cystic . [15]

24
1.10.2 Lithiasis on a foreign body [16]
It is well established that non -absorbable suture material may migrate into the lumen of the
bile duct and deliver the condensa tion nucleus on which presents a biliary lithiasis. There are reported
cases where the metal clips have displaced up to penetrate the bile duct from where they were
recovered , in the course of ERCP, on the center of lithiasi c formations. It is a very rare situation
whose reports a re sporadic. Currently seems that the prevention must go through the correct position
(parallel clips between them and not crossed) carefully avoiding the thermal and ischemic damage to
the bile duct. Perhaps the genesis of this complication is linked to the necrosis of a portion of the
cystic stump or of the biliary tract with the clips migration, subsequent the growth of the calculation
and finally the obstruction of the bile duct [16]

1.11 Complication liked to the perforation o f the gallbladder and the lithiasic spill
Abscesses of the wall [17]
In the international literature it is reported a perforation of the gallbladder with loss of the
content material with a variable percentage between one and 40%. This situation is usually evaluated
by surgeons as benign and does not deserve a specific treatment. In fact, are reported septic
complications , also delayed by several months compared to the intervention of VLC .
The perforation of the gallbladder typically takes place in four st ages:
1. During the dissection from the liver bed for drilling with the dissector,
2. As a result of the displacement of a clip,
3. As a result of tractions (true and proper tear) on the organ during surgery and
4. During the 'extraction of the gallbladder through the abdominal wall.
Of course, the quantity of gallstones and bile released into the peritoneum depends from the nature
of the perforation and, presumably, also the frequency of these complications. An important role in
the pathoge nesis could be the bile infection present in approximately 15 -30% of cases.
The presence of an acute inflammation of the organ is associated with an increased incidence
of perforation , mainly linked to a greater fragility of the wall , which more easily can be damaged
during norm al surgical maneuvers.
The i nfectious complications can be divided into two main categories:
1. The first, with less severe clinical implications, encloses the abscesses of the abdominal wall
linked to the loss of calculations during the extraction of the ga llbladder from the wall itself;
2. The second, clinically more important, refers to sys temic infections up to: septicemia,
adhesions, fistulas and especially to the formation of intraperitoneal ab scesses, mainly in the
sub-hepatic or sub -phrenic space but al so in the pelvis, omental an d paracolic space .

25
The most important means to prevent these complications is prevention; the surgeon must avoid
as much as possible the lesio ns of the gallbladder, recovering , however, all calculations also those of
minimum siz e. Furtherm ore, it is necessary perform an accurate cleaning by abundantly flushing and
subsequently aspirating all the liquid. The use of aids , such as endobag , can be usefu l but secondary
to the care to put in av oiding injuries.
In conclusion, we can say :
• gallstones in the peritoneum can cause illness;
• complications also severe , as rare, may occur and may cause diagnostic doubts;
• every possible precaution must be put into practice to prevent the spreading of gallstone s and
bile into the peritoneum dur ing the VLC surgery
• If a lot of calculations, including those discharged into the peritoneum, cannot be found during
the laparoscopic inspection , in the presence of BC (bacterial cholangitis) must be performed
a laparotomy conversion given the high incidence o f infectious complications;
• the abdo minal cavity should be regularly irrigated after a perforation of the gallblad der in
order to dilute the infected bile;
• in any case , perform chemical and bacteriological examination of the gallstones ;
• The bile should be placed in culture to provide any information about the possible bacterial
colonization and an eventual antibiogram that will be useful in case of complications;
• treating an intra -abdominal abscess with a simple drainage is often ineffective and requires a
“open” surgical approach;
• Consider a “high risk of perforation of the gallbladder ” the patients with hydrops (dimensions
gallbladder> 8x4x4 cm) and those suffering from acute cho lecystitis (with wall thickness > 7
mm). [17]

1.12 Imagining methods
In medic ine diagnostic imaging methods allow you to view an anatomical structure, verify the
functionality and the presence of any disease. Fifty years ago, diagnostic imaging in medicine was
based on x -ray fluoroscopy, and inventions that are more recently new have revolutionized the
diagnostic methods with the introduction of ultrasound, nuclear medicine and computed tomography
(the first imaging techn ique computer -aided). Then were introduced the techniques of nuclear
medicine , tomographic PET (Po sitron Emission Tomography), SPECT (Single Photon Emission
Computed Tomography) and magnetic resonance imaging (MRI). The methods currently considered
advanced level ( "Advanced Imaging") are thus computed tomography, ultrasonography, color
Doppler ultrasound imaging, MR I, PET, SPECT. [19]

26
Special Part

2.1 Aim and motivation of the study
This study wants to show pros and cons of the Video Laparoscopic surgery method and tries to find
some pattern of incidence of this inflammation among the patients of Arad.
Finding recurre nces like: Age and sex can also help on dete rmining who is at risk and why.
In literature, the reason of why a lithiasis occur is still a little mystery and analyzing the pattern of
recurrences of our patients can may be help in understanding some algorith m of appear.
I choose this study because is a problem that is easily found in surgery, it has root in diet, hormones
involved and lifestyle. If we can understand how and why an inflamed gallbladder reach this state
may be avoiding some life behavior that w e all have, we can easily avoid the hill itself.

27
2.2 Material and methods
The study is based on the analysis of the clinical records of 197 patients with cholecystitis (acute or
chronic acutized) recovered at Spital municipal of Arad.
From the analysis of these clinical records, I took in consideration various parameters, useful for the
study. These cases refer s to the year 2016.
The parameters checked are the following:
Gender
Age
Conversions
Dimension of the Gallstones
Acute or Chronic Acutiz ed
Association with adherence syndrome
Associated Pathologies
Intra -operative incidence and complications
Duration of the operation
These parameters are organized and represented in tables and graphics to show statistic studies and
percentages. Statistics evicted by this study are also comparated with those are yet present in the
medicine literature using the appropriate references.

28
2.3 Results
2.3.1 Gender
From our 197 patients 42 were male and 155 were female. As the pie chart (Chart 1) shows, the
predominance of Cholecystitis is in women.

In the table below patients and percentage :

Sex Number of patients %
Male 42 21.31
Female 155 78.69
Chart 1. Distribution of the colecystithis based on sex

29
2.3.2 Age of the patients
From the analysi s of the cases (c hart.2/chart 3 ):
 33.5% of the patients were o ver 60 years old
 26.4% of the patients were between 51 and 60 years
 20.3% of the patients were between 41 and 50 years
 15.2% of the patients were between 31 and 40 years
 4.6% of the patients were between 25 and 30 years
 No cases under 25 years (0%)
Chart 2 Distribution of the colecystithis based on age

30

Chart 3 Distribution of the colecystithis based on age

31
2.3.3 Operative approaches and conversions
In our cases, 12 times the operation has been converted from the VL to Clas sic “Open” due to
complications and 10 started as classic “open ” from the beginning due to patient issue ( chart4) :
 175 laparoscopic approach
 12 conversions
 10 classic s “Open ”

The episodes that needed a conversion represent less than 7 % of the total operations. In our cases
the issues where (chart 5):
 Adherence block: 4 cases
 Main biliary duct lesion : 2 cases
 Gallbladder bed hemorr hage: 3 cases
 Hemorrhages from the cystic artery branches : 3 cases

Chart 4 Operative approach incidence

32

2.3.4 Dimension and quantity of the gallstones
Is obvious that the gallstone comes in different dimension and quantity (chart 6):
 23 single gallstone
 175 multiple

Chart 5 Conversio n reasons
Chart 6 Multiple/single gallstone ratio

33

Chart 7 dimension of single gallstones found
Chart 8 dimension of the multiple gallstones found

34
2.3.5 Acute or chronic acutized
We ca n find difference, also taking in analysis acute or acutized episodes, and compare them based
on sex (chart 9, 10, 11):
Sex Acute Chronic Acutized
Men 26 16
Women 68 87

Chart 9 Acute or chronic acutized ratio based on all the cases

35

Chart 10 Acute or chronic acutized ratio based on women

Chart 11 Acute or chronic acutized ratio b ased on men

36
2.3.6 Associ ation with adherence syndrome (with \ without)
Men

Acute Chronic Acutized
Number of cases 26 16
Lisys 9 12
Chart 12 Associ ation with adherence syndrome in m en with acute inflammation
Chart 13 Associ ation with adherence syndrome in me n with chronic inflammation acutized

37
Women
Acute Chronic Acutized
Number of cases 68 87
Lysis 28 65

Chart 14 Associ ation with adherence syndrome in women with acute inflammation
Chart 15 Associ ation with adherence syndrome in women with chronic inflammation acutized

38
2.3.7 Associated Pathologies
I could noticed (chart 16) that the most common associated pathology is the Umbilical hernia, in the
literature the conversion of the operation to an “open” one is due to a previous abdominal operation
The ones the we encountered are (chart 17) :
 Ovarian cystectomy 0.6% of the total cases
 Sub-umbilical hernia 1.5% of the total cases
 Umbilical hernia 2.5% of the total cases

Chart 16 Associ ated pathologies with the cholecystectomy
Chart 17 Associ ated pathologies with the
cholecystectomy ratio

39
2.3.8 Intra operative inciden ce and complication (accidents)
Accidents always occurs, during the year toke in consideration, we had 23 accidents:
 2 cases of main biliary duct lesion
 9 cases of gallbladder bed hemorr hage
 12 hemorrhages from the cystic artery branches
23 case on 197 represent 11.7% incid ence of accidents .

Chart 18 intra -operati ve accidents
Chart 19 intra -operati ve accidents
ratio

40
2.4 Discussion
2.4.1 Gender
Taking in consideration the Sex of the patients, we can easily say that the women of Arad are more
susceptible to this inflammation repr esenting almost the 80% of the total cases (chart 20 , 21).
Sex Number of patients %
Male 42 21.31
Female 155 78.69

Cholelithiasis is a widespread condition characterized by the presence of calculations in gallbladder
and / or biliary tract; Women are more interested , with a female / male ratio of 2 to 1.
Acute cholecystitis is an acute inflammation of the gall bladder wall, accompanied by cholelithiasis
in 95% of cases; chronic form is often characterized by recurrent colic and a contracted, fibrotic
gallbladder, thi ckened walls
We know that the gallstones are divided into 2 sub -genres:
 Cholesterol Stones: composed mainly of cholesterol (the most frequent)
 Pigment Stones: composed of calcium bilirubinate, or calcified bilirubin. Black or brown in
color.
Knowing tha t the estrogen encourages the cholesterol production, we can understand why the
cholelithiasis is mostly present in women . [23]

Chart 20,21: gender rati o between our cases and the lit erature

41
2.4.2 Age of the patients

Gallbladder (or gall bladder) calculations affect about 8 0% of people after 40 years and frequenc y
tends to increase with age. In most cases, they do not give any symptoms. This is why laparoscopic
cholecystectomy (removal of the gall bladder), today a first -rate intervention, should only be
reserved for specific cases . [22]

In our study:
 33.5% of the patients were over 60 years old
 26.4% of the patients were between 51 and 60 years
 20.3% of the patients were between 41 and 50 years
 15.2% of the patients were between 31 and 40 years
 4.6% of the patients were between 25 and 30 years
 No cases under 25 years (0%)

So the pattern of our study follow the pattern found in literature, because also most of our patients
were over 40 years old (chart 22).

Chart 22 variance by age between our cases and literature

42
2.4.3 Operator approaches and conversions
One of the complications of cholecystectomy is the lesions of th e bile ducts, which occur, in the case
of laparoscopic surgery, in 0.5 -1% of cases.
The episodes that needed a conversion represent less than 1% of the total operations. In our cases the
issues where:
a. Adherence block: 2 cases
b. Hemorrhage: 1 case
Conversion of laparoscopic technique to traditional laparotomy technique is performed when the
surgeon judges that continuation of laparoscopic surgery increases the risk of complications for the
patient. The conversion rate varies in international literature from 0. 6 to 13% and is greatly influenced
by the experience of the surgical team. The most common reason for conversion is adhesions, and the
majority of these patients had prior abdominal surgery . [24]
So also on the conversions rate our study does not differ mu ch from the literature.
2.4.4 Dimension and quantity of the gallstones
Our study shows that when the gallstone is single, it mostly will be a big one or any way in the order
of >1 cm.
Taking in consideration the data we can understand that the single gallstone is rare r (23 cases out of
197), in fact in the most cases there were multiple micro -gallstones smaller than 0 , 5 cm (174 cases
out of 197)
2.4.5 Acute or chronic acutized
We can find difference, also taking in analysis acute or acutized episodes, and compare them based
on sex:
Our study shows a perfect balance between acute and chronic acutized colecystithis . In fact, without
taking the gender in consideration we have:
 52% chronic acutized episodes
 48% acute colecystithis
The main differences comes out if we bas e on the gender:

43
In men:
 62% were Acute
 38% were Chronic acutized
In women, we have quite the opposite:
 56% were Chronic Acutized
 44% were Acute
May be we can assume that the frequent acutiziation of the colecistithis in women is always due to
estrogen.
2.4.6 Association with adherence syndrome (with \without )

The adherence syndrome is most common with a chronic colecystithis (75% of the cases) but from
our study is obvious that the gende r has a great influence on the appearance of the adherence
syndrome, in fact in our case (chart 23 , 24):
 In man with acute colecystithis 65% of them showed lysis of adherences, in women instead,
just the 41%
 For what concern the Chronic Acutized syndrome there is a surpr ising equivalence of data
bot 25% without and 75% with lysis Acute (cases/lysis) Chronic Acutized(cases/lysis)
94 103
37 77

44

Chart 23 Associ ation with /without adherence syndrome in patients with acute inflammation
Chart 24 Associ ation with /without adherence syndrome in patients with chronic inflammation acutized

45
2.4.7 Associated Pathologies
In literature, the associated pathologies are various and are showed with a very variable percentage
among the worldwide population. In Our particular study, we had 9 cases with an associated
pathology :
 Ovarian cystectomy 1 case
 Sub-umbilical hernia 3 cases
 Umbilical hernia 5 cases
We could assume that the Umbilical hernia is the most frequent but the cases are so few that is hard
to extrapolate a plausible conclusion.
2.4.8 Intra operative incidence and complication (accidents)
A report of a similar study of the department of surgery science in the University of Pavia says:
Regarding complications related to VLC interventions from 1993 to 2010, we found 44 cases in
1,047 patients (4.56%), of, which (chart 25) :
 18 were bleeding (12 of them were because of the Trocars),
 15 subjected to conversion
 11 lesions at different levels of biliary tract. [23]

Chart 25 Intra -operative incid ence in literature

46
We can compare their ca ses with complications and ours (Chart 26) :

Considerin g that, some our cases requested a conversion we had (chart27) :
 12 conve rsions
 21 hemorrhages
 2 lesions

Therefore, in our year of study most of the complications have been hemorrhages like in the Italian
study . But we encountered less lesion and the conversions ratio is alm ost the same.

Chart 26 comparison between literature cases and ours

Chart 27 Accidents ration in our study

47
CONCLUSIONS

The Video -laparoscopic surgery has emerged thanks to the undoubted advantages offered over
conventional open surgery: Surgery traditionally known as "the brutal craft" finally became a bit
'more "patient friendly". Next to this, the VL surgery allows, if well practiced, to reduce the social
costs of the diseases subject to surgical treatment.
This works shows that in laparoscopic surgery are highly importa nt three aspects:
1. Who: the surgeon who is interested in Video surgery must be gone through special training.
The training begins with a theoretical phase followed by several hours of application to the
simulator and then move on to clinical phase that stil l provides for a learning curve far from
immediate. In this phase, under the supervision of a tutor, however there is a risk of causing
serious damage. Even after the end of the learning period, the risks are not over: surgery is a
profession full of pitfa lls and who is not well prepared and cautious sooner or later pay the
consequences;
2. When: the timing of Video surgery is different from that of “open” surgery. Interventions that
once could be postponed today should be treated immediately with less risk fo r the patient
and lower costs for society;
3. Where: the Video surgery requires a series of equipment that must all be available
simultaneously to work in safety.
The patient thanks to the VL techniques certainly undergoes a minor surgical trauma compared to
conventional open surgical therapies, but still requires an adequate period of recovery and control.
The request for a short stay in hospital often prevents clinical control with all the serious medical and
legal implications that may arise; in other word s, an intervention in VL is still a surgery with many
advantages, but also many risks.

48
BIBLIOGRAFY

1. Reddy YP, Sheridan WG: Port -site metastasis
following laparoscopic cholecystectomy: a
review of the literature and a case report.Eur J
Surg Oncol 200 0 Feb;26(1):95 -8
Carmarthen and District NHS Trust, West
Wales General Hospital, UK.

2. Giuliante F, Vellone M, Fianchini M, Nuzzo G:
The surgical risk of laparoscopic
cholecystectomy.Ann Ital Chir 1998 Nov –
Dec;69(6):723 -9
Universita Cattolica del Sacro Cuor e, Roma.

3. Surgical Laparoscopy edited by Karl A. Zucker
(second edition Lippincott and wilkins)

4. Sanz -Lopez R, Martinez -Ramos C, Nunez –
Pena JR, Ruiz de Gopegui M, Pastor -Sirera L,
Tamames -Escobar S: Incisional hernias after
laparoscopic vs open cholecystec tomy.

5. MacFadyen Jr BV, Vecchio R, Ricardo AE,
Mathis CR: Bile duct injury after laparoscopic
cholecystectomy. The United States
experience. Surg Endosc 1998 Apr;12(4):315 –
21

6. Laparoscopy and Imaging Techniques
Di Giorgio Dagnini

7. Human Microscopic Anatomy : An Atlas for
Students of Medicine and Biology
Di Radivoj V. Krstic

8. Imaging Atlas of the Normal Gallbladder and
Its Variants
Di Jon W. Meilstrup, M.D.

9. Laparoscopic surgery
Jorge Cueto -García, Moisés Jacobs, Michel
Gagner McGraw -Hill, 2003

10. Laparoscopic Surgery: A Colloquium edited by
Ronald C. Merrell yale university school of
medicine

11. Reddy YP, Sheridan WG: Port -site metastasis
following laparoscopic cholecystectomy: a
review of the literature and a case report. Eur J
Surg Oncol 2000 12. Dixon M, Carril lo EH: Iliac vascular injuries
during elective laparoscopic surgery. Surg
Endosc 1999

13. Hanney RM, Alle KM, Cregan PC: Major
vascular injury and laparoscopy Department of
Surgery, University of Sydney, Nepean
Hospital, Penrith, NSW, Australia.
14. Croce E, Goli a M, Russo R, Azzola M, Olmi S,
De Murtas G: Duodenal perforations after
laparoscopic cholecystectomy. Surg Endosc

15. Alberts MS, Fenoglio M, Ratzer E: Recurrent
common bile duct stones containing metallic
clips following laparoscopic common bile duct
explor ation. J Laparoendosc Adv Surg Tech A
1999 Oct;9(5):441 -4 Department of Surgery,
Exempla Saint Joseph Hospital, Denver,
Colorado 80218, USA.

16. Prevention & Management of
Laparoendoscopic Surgical Complications
editors: Michael S.Kavic. MD; Carl .levinson.
MD; Paul Alan Wetter. MD

17. Preciado A, Matthews BD, Scarborough TK,
Marti JL, Reardon PR, Weinstein GS, Bennett
M.: Transdiaphragmatic abscess: late thoracic
complication of laparoscopiccholecystectomy.
J Laparoendosc Adv Surg Tech A 1999
Dec;9(6):517 -21
Department of Surgery, Baylor College of
Medicine, Houston, Texas, USA.

18. Laparoskopi Trokar Girișleri,
Komplikasyonlar ve Yönetimi Prof.Cem
FIÇICIOGLU, MD.,Ph.D., AA., MBA.

19. Humanitas research hospital
http://www.humanitas.it/visite –
esami/metodic he-di-imaging -avanzato

20. http://www.sabes.it/download/2015_07_21_P
R_Colecistect_laparosc_Allegato_1_Indicator
e_CHE_Razionale.pdf

49
21. http://medicine.academic.ru/6522/Porcelain_g
allbladder

22. http://www.wajradiology.org/article.asp?issn=
1115 –
3474;year=2013;volume=20;issue=1;spage=4;
epage=8;aulast=Adeyekun

23. Errore chirurgico, indice di rischio e
colecistectomia videolaparoscopica
Ferdinando Fichtner, Massimo Amboldi,
Martina Giussani, Jacopo Catto Ronchino,
Simona Boarin, Luigi Bonandrini
Dipartimento di Scienze Chirurgiche, Polo
Universitario Città di Pavia, Università degli
Studi di Pavia, Pavia, Italia

24. http://www.renatodemagistris.net/lavori11.ht
m