OBJECTIVE: Laparoscopic cholecystectomy, introduced in 1985 by Prof. Dr. Erich Mühe, has become the gold standard for treating chronic symptomatic calculous cholecystopathy and acute cholecystitis, with an estimated 750,000 procedures performed annually in the United States of America. The risk of iatrogenic bile duct injury persists, ranging from 0.2 to 1.3%. Risk factors include male gender, obesity, acute cholecystitis, previous hepatobiliary surgery, and anatomical variations in Calot\'s triangle. Strategies to mitigate bile duct injury include the Critical View of Safety and fundus-first dissection, along with intraoperative cholangiography and alternative approaches like subtotal cholecystectomy.
METHODS: This paper introduces the shoeshine technique, a maneuver designed to achieve atraumatic exposure of anatomical structures, local hemostatic control, and ease of infundibulum mobilization. This technique involves the use of a blunt dissection tool and gauze to create traction and enhance visibility in Calot\'s triangle, particularly beneficial in cases of severe inflammation. Steps include using the critical view of safety and Rouviere\'s sulcus line for orientation, followed by careful dissection and traction with gauze to maintain stability and reduce the risk of instrument slippage.
RESULTS: The technique, routinely used by the authors in over 2000 cases, has shown to enhance patient safety and reduce bile duct injury risks.
CONCLUSIONS: The shoeshine technique represents a simple and easy way to apply maneuver that can help surgeon during laparoscopic cholecystectomies exposing the hepatocystic area and promote blunt dissection.

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Anatomical variations of the biliary tree pose diagnostic and treatment challenges. While most are harmless and often discovered incidentally during procedures, some can lead to clinical issues and biliary complications, making knowledge of these variants crucial to prevent surgical mishaps. Here, we present an unusual and clinically significant case. A 61-year-old man is admitted to the hospital with epigastric pain and diagnosis of pancreatitis of biliary origin and intermediate risk of choledocholithiasis. Magnetic resonance cholangiopancreatography (MRCP) reported hepatolithiasis and choledocholithiasis, whereas endoscopic retrograde cholangiopancreatography showed cystic drain of the right hepatic duct. One month later the patient presented again to the emergency room with increasing abdominal pain and a computed tomography that demonstrated the presence of hepatic abscess and acute cholecystitis. The patient underwent percutaneous drain abscess and a subtotal laparoscopic cholecystectomy. Biliary anatomical variants present challenges on the diagnostic investigations, interventional and surgical procedures, understanding the possible complications is essential.

BACKGROUND: Gallstones are common lesions that often require surgical intervention. Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones. Preoperatively, the anatomical morphology of the cystic duct (CD), needs to be accurately recognized, especially when anatomical variations occur in the CD, which is otherwise prone to bile duct injury. However, at present, there is no optimal classification system for CD morphology applicable in clinical practice, and the relationship between anatomical variations in CDs and gallstones remains to be explored.
OBJECTIVE: To create a more comprehensive clinically applicable classification of the morphology of CD and to explore the correlations between anatomic variants of CD and gallstones.
METHODS: A total of 300 patients were retrospectively enrolled from October 2021 to January 2022. The patients were divided into two groups: The gallstone group and the nongallstone group. Relevant clinical data and anatomical data of the CD based on magnetic resonance cholangiopancreatography (MRCP) were collected and analyzed to propose a morphological classification system of the CD and to explore its relationship with gallstones. Multivariate analysis was performed using logistic regression analyses to identify the independent risk factors using variables that were significant in the univariate analysis.
RESULTS: Of the 300 patients enrolled in this study, 200 (66.7%) had gallstones. The mean age was 48.10 ± 13.30 years, 142 (47.3%) were male, and 158 (52.7%) were female. A total of 55.7% of the patients had a body mass index (BMI) ≥ 24 kg/m2. Based on the MRCP, the CD anatomical typology is divided into four types: Type I: Linear, type II: n-shaped, type III: S-shaped, and type IV: W-shaped. Univariate analysis revealed differences between the gallstone and nongallstone groups in relation to sex, BMI, cholesterol, triglycerides, morphology of CD, site of CD insertion into the extrahepatic bile duct, length of CD, and angle between the common hepatic duct and CD. According to the multivariate analysis, female, BMI (≥ 24 kg/m2), and CD morphology [n-shaped: Odds ratio (OR) = 10.97, 95% confidence interval (95%CI): 5.22-23.07, P < 0.001; S-shaped: OR = 4.43, 95%CI: 1.64-11.95, P = 0.003; W-shaped: OR = 7.74, 95%CI: 1.88-31.78, P = 0.005] were significantly associated with gallstones.
CONCLUSIONS: The present study details the morphological variation in the CD and confirms that CD tortuosity is an independent risk factor for gallstones.

Acute cholecystitis is a common cause of Emergency Department presentation and hospital admission. It is usually treated with early surgical removal of the gallbladder; however, some patients may not be fit to undergo the procedure due to critical illness or comorbidities. In these patients, options are limited. Endoscopic retrograde cholangiopancreatography interventions in this population are not well-studied. We present a case of a high-risk 59 year old female patient with a history of end-stage renal disease, heart failure, hypertension, pulmonary hypertension, and type 2 diabetes who presented with acute cholecystitis. She was successfully treated with cystic duct disimpaction without stenting, and continues to do well post-procedure with complete resolution of symptoms and abnormal lab findings.

The aim of this manuscript is to illustrate a new method permitting safe cholecystectomy in terms of complications with respect to the common bile duct (CBD).
The core of this new technique is identification of the continuity of the cystic duct with the infundibulum. The cystic duct can be identified between the inner gallbladder wall and inflamed outer wall.
In the last 2 years, from January 2019 until December 2021, 3 patients have been treated with the reported technique without complications.
Among the various cholecystectomy procedures, this is a new approach that ensures the safety of the structures of Calot\'s triangle while providing the advantages gained from total removal of the gallbladder.

UNASSIGNED: Biliary cysts are rare congenital anomalies of the biliary ductal system. Cystic duct cysts in particular are not included in the widely used Todani classification and remain underreported.
METHODS: A 28-year-old male presented with intermittent right upper quadrant pain exacerbated by fatty foods. Ultrasound showed a septate gallbladder. Laboratory tests were normal. Laparoscopic cholecystectomy identified a 1.5 cm cystic duct cyst.
UNASSIGNED: Cystic duct cysts arise from anomalous ductal recanalization/dilatation. Presentation mimics cholelithiasis. Complete surgical excision is the treatment to prevent complications.
CONCLUSIONS: This case presents an incidental finding of a cystic duct cyst resected during cholecystectomy for septate gallbladder. Increased recognition can improve the management of these rare biliary anomalies.

High-grade dysplasia (HGD) in the cystic duct is a rare epithelial lesion that may lead to biliary tract malignancy. Due to its association with aggressive multifocal cholangiocarcinoma, it is important to investigate for concurrent malignancy, remove all areas of HGD and monitor for recurrence or metastasis.We present a case of a woman in her 60s with cholecystitis who underwent a laparoscopic cholecystectomy. On histopathology, the patient was found to have incidental HGD involving the cystic duct margin. After ensuring the absence of concurrent malignancy on cross-sectional imaging, she underwent further resection until the margins were clear of dysplasia. In the absence of clear follow-up guidelines, the patient was closely monitored with outpatient scans for up to 5 years.