Abstract
Introduction
Significant discrepancies exist between surgeon-documented and actual rates of critical view of safety (CVS) achievement on retrospective review following laparoscopic cholecystectomy. This discrepancy may be due to surgeon utilisation of the artery first technique (AFT), an exception to the CVS first described by Strasberg et al. The present study aims to characterise the use of the AFT, hypothesising it is used as an adjunct in difficult dissections to maximise exposure of the hepato-cystic triangle ensuring safe cholecystectomy.
Methods
Prospective digital recording of the operative procedure of patients’ undergoing laparoscopic cholecystectomy were undertaken at Christchurch Public Hospital, New Zealand and North Shore Private Hospital, Sydney, Australia. Videos were uploaded to Touch Surgery™ Enterprise. Difficulty was graded, annotated and indications for the AFT quantified using a standardised protocol.
Results
A total of 275 annotated procedures were included in this study. The AFT was employed in 54 (20%) patients; in 13 (24%) patients for bleeding, in 35 (65%) patients where windows one and two were visible, and in 6 (11%) patients no windows were visible within the hepato-cystic triangle. There were significant differences in utilisation across operative grade and by seniority of operator (p < 0.005).
Conclusions
The data presented here demonstrate the AFT is frequently used, particularly with Grade 3 cholecystectomy. However, more data are needed to confirm the utility and safety of this approach. Analysis of the AFT shows that to understand and improve safety in laparoscopic cholecystectomy appreciating how the operation was undertaken and not just that the CVS was achieved is crucial.
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Acknowledgements
With thanks to Digital Surgery Ltd, a Medtronic company, for access to Touch SurgeryTM Enterprise for both video recording and analysis throughout this study.
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The first author of this study, Isaac Tranter-Entwistle, has received funding from Medtronic to undertake a PhD. The video upload and annotation was performed using Touch Surgery™ Enterprise, developed by Digital Surgery Ltd, a Medtronic company. The Touch Surgery™ application is freely available software for surgical trainee education. The authors have consulted on the development of a number of educational modules on the Touch Surgery™ application, including laparoscopic cholecystectomy, and have provided feedback on a few R&D projects with Medtronic. Study conceptualization, design, operative video recording, performance and analysis were all independent of Medtronic staff. Thomas Hugh has undertaken consultancy for Digital Surgery Ltd separate to the present study and was not involved in the analysis of results in this study. Saxon Connor has undertaken pro bono consultancy for Digital Surgery LTD developing a freely available educational application around laparoscopic cholecystectomy, as well as video annotation as part of an unrelated study. Tim Eglinton has undertaken consultancy for Digital Surgery Ltd separate to the present study.
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Tranter-Entwistle, I., Eglinton, T., Hugh, T.J. et al. The artery first technique: re-examining the critical view of safety during laparoscopic cholecystectomy. Surg Endosc 37, 4458–4465 (2023). https://doi.org/10.1007/s00464-023-09912-z
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DOI: https://doi.org/10.1007/s00464-023-09912-z