Fundus first as the standard technique for laparoscopic cholecystectomy

Area of Science:

• Surgical Innovation
• Gastrointestinal Surgery
• Minimally Invasive Procedures

Background:

• The fundus-first (FF) technique simplifies laparoscopic cholecystectomy (LC) and aids patient recovery.
• Previous studies highlighted FF as cost-effective and beneficial for rehabilitation.

Purpose of the Study:

• To assess the feasibility and safety of establishing FF as the standard LC technique.
• To compare complication rates between FF and conventional LC approaches.

Main Methods:

• A retrospective analysis of 1745 LC procedures (1425 FF, 320 conventional) performed by 29 surgeons between 2004-2014.
• Evaluation of operative characteristics, complication types, and risk factors for bile duct injury.

Main Results:

• FF adoption increased from 56% in the first year to 98% in the last four years.
• FF was associated with more females, ultrasonic shears, urgent/daycare operations, and shorter operation times.
• Overall complications were 3.6% (10 bleeding, 33 infection, 12 bile leakage).
• Cystic duct leakage was higher with ultrasonic shears (3.6%) vs. clips (0.2%).
• Common bile duct (CBD) lesions were lower with FF (0.07%) vs. conventional (0.9%).
• Conventional technique was a significant risk factor for CBD injury (OR 20.8).

Conclusions:

• FF was successfully implemented as a standard LC procedure, demonstrating safety and efficacy.
• FF is associated with a significantly lower incidence of bile duct injuries compared to the conventional approach.
• Clipless closure of the cystic duct during FF LC increases the risk of bile leakage.