Surgeries

Background: Lung cancer surgery often involves complex decision-making, where accurate and interpretable predictive models are crucial for assessing postoperative risks and optimizing outcomes. This study presents XplainLungSHAP, a novel framework combining SHAP (SHapley Additive exPlanations) and attention mechanisms to enhance both predictive accuracy and transparency. The aim is to support clinicians in preoperative evaluations by identifying and prioritizing key clinical features. Methods: The framework was developed using data from 470 patients undergoing lung cancer surgery. Key clinical features were identified through SHAP, ensuring alignment with medical expertise. These features were dynamically weighted using an attention mechanism in a neural network, enhancing their impact on survival predictions. The model’s performance was evaluated through accuracy, confusion matrices, and ROC analysis, demonstrating its reliability and interpretability. Results: The XplainLungSHAP model achieved an accuracy of 91.49%, outperforming traditional machine learning models. SHAP analysis identified critical predictors, including pulmonary function, comorbidities, and age, while the attention mechanism prioritized these features dynamically. The combined approach ensured high accuracy and offered actionable insights into survival predictions. Conclusions: XplainLungSHAP addresses the limitations of black-box models by integrating explainability with state-of-the-art predictive techniques. This framework provides a transparent and clinically relevant tool for guiding surgical decisions, supporting personalized care, and advancing AI applications in thoracic oncology. Full article

Background/Objectives: Among the scientific literature, the significant potential of the application of artificial intelligence (AI) in minimally invasive surgery (MIS) stands out. The aim of this study is to provide a comprehensive review to analyze the scientific literature on AI applications in MIS training, selecting the main applications, limitations, opportunities and challenges in this field of research. Methods/Design: A literature search was conducted in scientific databases. The search was performed with titles or abstracts, using keywords. First, studies unrelated to the topic of study were eliminated. Next, the selection was limited to articles in English. The exclusion criteria for the search were reviews, letters, case reports, industrial articles and conference abstracts. Next, only studies published in the last ten years (2014–2024) were evaluated, with priority given to publications in the last five years (2019–2024) in surgical training in AI and MIS. Finally, the full text was reviewed to add or exclude the study from this review. Results: Of the 54 studies included in this review, 18 studies were related to skills assessment, 30 studies analyzed aspects of surgical training itself, 12 studies were related to learning aspects of surgical planning, 7 studies were based on gesture recognition and 3 studies were based on surgical action recognition to measure surgical performance during MIS training. A brief description of the main AI techniques was included in this review. Conclusions: The application of AI in MIS surgical training is still a developing field of research, which presents great potential for exploring future applications, challenges, opportunities and drawbacks, as well as synergies between the technical and clinical research fields. Full article

It was in 1989 that we first reported on the use of the radial artery (RA) as a secondary arterial graft for coronary artery bypass grafting (CABG). Nevertheless, discrepancies in clinical endpoints between the RA and alternative conduits have been reported in consecutive randomised trials. With over fifty years of accumulated practice in RA bypass grafting, we sought to identify the second-best option for CABG by reviewing the literature. A consistently successful second-best conduit for CABG has been demonstrated using the radial artery. Compared to saphenous vein grafts, the findings indicate improved outcomes and better patency results. Furthermore, it has been demonstrated to be a safe and effective conduit in the territory of the right coronary artery. The lack of available literature and the scarcity of similar case series restrict the application of the gastroepiploic artery. After five decades of utilisation, it can be unequivocally stated that the radial artery is the optimal conduit for coronary bypass surgery following the left internal thoracic artery to the left anterior descending artery. Full article

Background/Objectives: Pressure injuries (PIs) are injuries to the skin and underlying tissue localized over a bony prominence. Surgical complications following the closure of a PI include ulcer recurrence, wound dehiscence, hematomas, and infection, which pose significant morbidity issues to patients. The objective of this study is to characterize the relationship between BMI and early and late wound outcomes following surgical closure through a secondary analysis of a previous study examining the effect of two support surfaces on PI healing. Methods: A single institution study on patients with a stage 3/4 pressure injury admitted for surgical closure was conducted. The subjects were monitored for 14 days post-closure (POD-14) so that an assessment of their early wound status and complications, including moisture, maceration, drainage, dehiscence, epidermolysis, necrosis, and demarcation, could be conducted. Results: In total, 68 patients were included. Out of these, 13% of patients were underweight, 29% were normal-weight, 35% were overweight, and 22% were obese. POD-14 complications occurred in 22% of underweight patients, 15% of normal-weight patients, 38% of overweight patients, and 40% of obese patients. Of all recorded complications, 75% of patients were overweight or obese. Complication rates were not significantly different based on osteomyelitis status. The most common cultures identified in wounds were P. aeruginosa, S. aureus, and E. coli. Negative cultures were found in 22% of closed wounds and 13% of open wounds. Conclusions: Our findings suggest that BMIs may be correlated with early wound status and the incidence of postoperative complications, while it may not be correlated with osteomyelitis status. Future studies should further evaluate the effect of BMIs on pressure injury-associated complications. This may further guide preoperative planning and patient expectations. Full article

Aortic stenosis (AS) is the most common valve disease in developed countries, with severe cases traditionally managed through surgical aortic valve replacement (SAVR). More recently, transcatheter aortic valve replacement (TAVR) has been used as a less invasive alternative, especially for patients deemed high-risk for surgery. This review aims to compare SAVR and TAVR by examining the efficacy, patient selection criteria, complications, and evolving guidelines. SAVR is the preferred option for patients at low surgical risk or with anatomical challenges unsuitable for TAVR. It offers well-documented durability and favorable long-term survival. Conversely, TAVR has gained acceptance for intermediate- and high-risk patients, with shorter recovery times and reduced immediate postoperative risks. However, questions surrounding its long-term durability in younger populations persist. Complications differ between the approaches, with TAVR associated with vascular access injuries and arrhythmic events, while SAVR presents risks tied to open surgery. As clinical guidelines evolve, patient age, comorbidities, and life expectancy play critical roles in determining the optimal intervention. This review highlights the need for tailored treatment approaches, given the expanding indications and evolving evidence for both SAVR and TAVR in AS management. Full article

Background: This study evaluated the performance of machine learning models trained on two different datasets of knee X-ray images annotated with Kellgren–Lawrence grades. Methods: Learning curves indicated that one model experienced poor training, characterized by underfitting, while the other model demonstrated effective training with proper convergence. The poorly trained model appeared to perform adequately on its internal test set but failed to generalize to an external dataset, yielding suboptimal results. Results: In contrast, the well-trained model not only performed well on its internal validation but also showed adequate performance when tested on the external dataset. Conclusions: These findings highlight the importance of examining learning curves to assess model training quality and the critical necessity of external testing to evaluate generalizability. Most existing studies lack external validation, raising concerns about the reliability of their reported performance. This study emphasizes that without external testing, models may not perform as expected in real-world clinical settings, potentially impacting clinical decision-making for surgical interventions. The results advocate for the inclusion of external validation in model evaluation and the assessment of model convergence using learning curves to ensure the development of robust and generalizable tools for knee osteoarthritis severity assessment and other applications. Full article

Background: Diversity of gender representation in surgery is known to positively influence patient outcomes and predict career trajectories for female trainees. This study aims to identify the current and recent past state of gender diversity amongst trainees entering Canadian surgical residency programs. Methods: Data were sourced from the Canadian Post-M.D. Education Registry (CAPER) and the Canadian Resident Matching Service (CaRMs) for ten surgical specialties. CAPER data include PGY-1 trainees in all surgical specialties for the academic years 2012–2013 to 2021–2022. CaRMs provided data of total applicants and matched applicants for Canadian Medical Graduates (CMGs) in the match years 2013–2022. Results: From 2012–2022, there were 4011 PGY-1 surgical residents across Canada (50.4% female, 49.6% male). The surgical specialties with the most female representation were obstetrics/gynecology (82.1–91.9%), general surgery (40.2–70.7%), and plastic surgery (33.3–55.6%). The surgical specialties with the least female representation were neurosurgery (18.7–35.3%), urology (11.8–42%), and orthopedic surgery (17.5–38.5%). The number of female applicants to surgical programs has increased since 2013 and outnumbers male applicants each subsequent year. The match rate to surgical programs for female applicants has varied by year, with the highest being 63.9% in 2014 and the lowest in 2018 at 48.8%. Conclusions: Our study shows promising trends that reflect increased representation of female trainees. However, while the number of female trainees in general surgery and obstetrics/gynecology programs matches and even exceeds Canadian demographic proportions, this is not true for most other surgical specialties. This calls for continued efforts to improve and retain gender equity across surgical specialties in Canada. Full article

Background/Objectives: Myocardial revascularization surgery (MR) is routinely performed in hospitals. However, there is a lack of an algorithm in the scientific literature aimed at predicting intraoperative parameters, such as total surgery time (TST) and cardiopulmonary bypass time (CBT), based on preoperative MR parameters. Therefore, the objective of the present study is to apply a complex network model to predict parameters associated with TST and CBT. Methods: Retrospective data from 124 patients who underwent MR, including medical history, vital signs, and laboratory/biochemical tests, were used, with 30 patients contributing to the construction of the network. Three complex networks were created to study the targets (TST and CBT). The Eigenvector metric was employed to investigate the parameters most relevant to these targets. Results: Regardless of the target, parameters derived from the blood gas analysis followed by erythrogram displayed greater relevance according to the eigenvector metric. However, for TST, the most prominent parameter was Red Blood Cells, while, for CBT, Diastolic Blood Pressure emerged as the most important variable. Conclusion: The targeted complex network model revealed that pulmonary, hemodynamic, and perfusion factors are relevant to the intraoperative parameters of MR. The networks also demonstrated that, although the targets show significant correlation with each other (TST and CBT-r = 0.76; p = 0.000), the importance of the parameters in the networks does not follow the same order. This reiterates the strength of the network in revealing specific information when a particular target is selected. Full article

Introduction: Refractory epilepsy is common in children with Autism Spectrum Disorder (ASD), significantly affecting their cognitive development and quality of life. Surgical interventions provide a therapeutic option, but it remains unclear which technique offers the best outcomes for this population. Objective: To compare the efficacy and safety of four surgical techniques—lesionectomy, temporal lobectomy, extratemporal cortical resection, and functional hemispherectomy—in children with refractory epilepsy, both with and without ASD, and evaluate their impact on cognitive and behavioral development and quality of life. Methodology: A retrospective study was conducted with 120 children diagnosed with refractory epilepsy, equally divided between those with and without ASD. Patients were assigned to one of four surgical groups (n = 15 per group) based on the intervention performed. Data on demographic and clinical characteristics, as well as one-year postoperative outcomes—including seizure control (Engel classification), intelligence quotient (WISC-V), adaptive behavior (Vineland-II), and quality of life (PedsQL)—were collected. Statistical analyses were applied to compare the results among groups, and logistic regression was used to identify the predictors of seizure freedom. Results: Lesionectomy and temporal lobectomy groups showed significantly higher rates of seizure freedom (80% and 73%, respectively) compared to extratemporal resection (60%) and functional hemispherectomy (67%). These groups also presented significant improvements in intelligence quotient, adaptive behavior, quality of life, and reductions in ASD symptoms (p < 0.01). Perioperative complications were notably lower in the lesionectomy and temporal lobectomy groups (7%) compared to extratemporal resection and functional hemispherectomy (40%; p = 0.007). Significant predictors of seizure freedom included the presence of structural anomalies on neuroimaging and a shorter duration of epilepsy before surgery (p < 0.05). Conclusions: Lesionectomy and temporal lobectomy are highly effective and safer surgical techniques for managing refractory epilepsy in children with ASD, providing significant benefits in seizure control, cognitive development, and quality of life. Importantly, the outcomes observed are not exclusive to children with ASD but likely reflect broader efficacy across pediatric epilepsy populations. The early identification of surgical candidates and comprehensive preoperative evaluations are essential for optimizing outcomes, emphasizing the importance of individualized treatment planning and further comparative research to validate these findings. Full article

Study Design: This was a single-institution, retrospective cohort study. Objective: The objective of this study was to assess a surgical technique for spinal reconstruction after corpectomy, integrating an allograft/autograft within a vertebral body replacement cage linked to spinal rods via pedicle screws. This method aims to enhance biomechanical stability and promote long-term fusion without cage endcaps. Summary of Background data: Recent advancements in spinal surgery feature innovative constructs that improve healing and fusion rates. FDA-approved mesh cages provide enhanced stability and superior fusion with fewer complications. Our approach combines allografts/autografts with vertebral replacements, using a pedicle screw through the cage for significant biomechanical enhancement. Methods: Two patients undergoing cervical and lumbar spinal reconstructions due to different pathologies were selected. The surgical technique involved shaping the allograft/autograft to fit precisely within the cage, extending beyond its ends to facilitate fusion at both ends, and securing the construct to the spinal rods with pedicle screws for added stability. Patient outcomes were assessed based on post-operative stability, fusion rates, and the presence of any complications. Results: Both cases successfully utilized the technique, achieving stabilization and fusion. Improvements were noted in post-operative recovery. There were no instances of cage subsidence, or any significant complications directly related to the novel construct. Conclusions: Our case series highlights a post-corpectomy reconstruction technique involving a mesh cage construct integrated with an autograft/allograft and connected to posterior instrumentation for enhanced stability. This technique was applied successfully in two cases, demonstrating its feasibility, durability, and potential to promote biological integration. Further studies with larger cohorts and extended follow-up periods are necessary to refine the approach for wider clinical use. Full article

Background/Objectives: Pediatric facial fractures present unique challenges due to the anatomical, physiological, and developmental differences in children’s facial structures. The growing facial bones in children complicate diagnosis and treatment. This review explores the advancements and complexities in managing pediatric facial fractures, focusing on innovations in diagnosis, treatment strategies, and multidisciplinary care. Methods: A narrative review was conducted, synthesizing data from English-language articles published between 2001 and 2024. Relevant studies were identified through databases such as PubMed, Scopus, Lilacs, Embase, and SciELO using keywords related to pediatric facial fractures. This narrative review focuses on anatomical challenges, advancements in diagnostic techniques, treatment approaches, and the role of interdisciplinary teams in management. Results: Key findings highlight advancements in imaging technologies, including three-dimensional computed tomography (3D CT) and magnetic resonance imaging (MRI), which have improved fracture diagnosis and preoperative planning. Minimally invasive techniques and bioresorbable implants have revolutionized treatment, reducing trauma and enhancing recovery. The integration of multidisciplinary teams, including pediatricians, psychologists, and speech therapists, has become crucial in addressing both the physical and emotional needs of patients. Emerging technologies such as 3D printing and computer-assisted navigation are shaping future treatment approaches. Conclusions: The management of pediatric facial fractures has significantly advanced due to innovations in imaging, surgical techniques, and the growing importance of interdisciplinary care. Despite these improvements, long-term follow-up remains critical to monitor potential complications. Ongoing research and collaboration are essential to refine treatment strategies and improve long-term outcomes for pediatric patients with facial trauma. Full article

Background/Objectives: Orthopedic hip surgery has undergone advances driven by innovations in surgical techniques and improved patient care protocols. The aim was to synthesize and appraise all studies relevant to hip surgery published in Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) in 2022–2023. Methods: The search included all studies published in KSSTA from 1 January 2022 to 31 December 2023. Quality assessment was performed using appropriate tools for randomized controlled trials (RCTs), non-RCTs, and systematic reviews. Due to the diverse nature of the included studies, a narrative synthesis approach was used. Results: A total of 33 primary studies were included in this narrative review, of which 10 were reviews (5 systematic reviews), 1 was an RCT, and 22 were non-RCTs. A total of 11 were from the UK, 10 studies were from the USA, and 5 were from Canada. Femoroacetabular impingement (FAI) was investigated in a total of 23 studies, followed by hip micro-instability in 7 studies, dysplasia in 5 studies, and gluteal and hamstring tears in 4 studies. The RCT had a low risk of bias. Of the 22 non-RCTs, 16 had a low risk of bias, 5 had a moderate risk of bias, and 1 had a high risk of bias. All systematic reviews were of moderate quality. Conclusions: Hip arthroscopy is an effective treatment for FAI with promising early outcomes, especially when combined with closed capsular repair and appropriate rehabilitation. Surgeons should tailor their approach to capsular management to optimize recovery, as closed capsular repair may enhance functional outcomes. Additionally, preoperative tools like the HAR Index can help identify patients at higher risk of requiring hip arthroplasty after surgery. The conclusions of the included primary studies align with current general recommendations and contribute valuable insights to the field of hip orthopedics. Full article

Background/Objectives: Patient acceptable symptom state (PASS) thresholds have been used as a marker of good functional outcome following total knee arthroplasty (TKA) but have not been applied to pre-operative subjective function. This study aimed to compare the outcomes of patients above and below PASS thresholds prior to TKA. Methods: A secondary analysis of a multicenter prospective observational study was used, including 1182 patients prescribed a smartphone-based care management platform following TKA with pre-operative and 1-year KOOS JR scores available. Patient demographics, pain, satisfaction, and KOOS JR were compared between those above and below PASS pre-operatively by student t-test. Logistic regression was used to quantify the odds of decline or no improvement at 1 year. Results: In this cohort, 191 (16.2%) KOOS JR scores were above PASS thresholds prior to TKA. Those above PASS reported lower pain pre-operatively (3.7 ± 1.9 vs. 6.0 ± 1.9, p < 0.0001) and less pain reduction at 90 days (−1.4 ± 2.5 vs. −3.2 ± 2.6, p < 0.0001). Patients above PASS also demonstrated higher KSS satisfaction scores pre-operatively (20.7 ± 7.9 vs. 12.1 ± 6.7, p < 0.0001) with less improvement (9.9 ± 10.6 vs. 16.5 ± 11.2, p < 0.0001) at 90 days. In logistic regression, those above PASS pre-operatively were 5.1 times more likely to report a decline or no improvement in KOOS JR at 1 year (5.10 95% CI 2.73–9.53, p < 0.0001). Conclusions: Patients above previously defined PASS thresholds who presented for TKA appreciated less improvement in pain and satisfaction and were more likely to experience functional decline or no improvement in KOOS JR post-operatively. The application of PASS thresholds pre-operatively may be useful for patient selection or guidance of patient expectations. Full article

Background: Adrenal cortical carcinoma (ACC) is a rare and aggressive malignant tumor with an estimated prevalence of 0.5–2 cases per million people. For patients with advanced or metastatic disease, the prognosis is very poor, and death usually occurs in the first 24 months after diagnosis. Some cases of ACC with invasion of the inferior vena cava (IVC) and the right atrium (RA) have been reported. Methods: We herein report an additional case of IVC and RA involvement in ACC in a 61-year-old woman with no relevant past medical history. Results: The patient underwent heart surgery to remove neoplastic thrombi in the IVC and RA; abdominal surgery to remove the adrenal mass was performed one month later, when the patient’s clinical condition was stable. Conclusions: The histologic and immunohistochemical features, as well as the differential diagnosis, are highlighted herein. Full article

Background/Objectives: Malpractice in cardiovascular surgery was addressed from the forensic pathology perspective, offering reflections on risk prevention in the Italian context. Litigation and risk management in healthcare, following the Italian law on safety of care, clinical risk management and professional liability, should be viewed in an integrated manner. Methods: We conducted a narrative review on litigation data and the principal areas of complaint in Italy regarding the cardiovascular field. The aim is to discuss human, communicative, organisational, technological and regulatory factors that may play a role in this phenomenon. Results: We discuss the importance of information and consent and the management and monitoring of competences, particularly in specialised activities, given the current human capital deficit. Furthermore, we focus on the centrality of the surgical indication focusing on benefit-risk balance in light of clinical guidelines and team-based evaluation, such as by an emergency heart team, to better tailor care to patients. At the facility level, the minimum volume of activity and the requirements for human resources, specialisations, technologies and organisation standards needed for health activity authorisation are highlighted as foundational to risk prevention. Furthermore, we discussed the availability of the minimum diagnostic and care tools in compliance with guidelines and the role of company clinical and organisational protocols. Conclusions: In the surgical, time-sensitive, highly specialised and technologically advanced sector, the importance of enterprise risk prevention and broad, value-based governance to ensure healthcare quality and safety is emphasised. Full article

Background: The increasing incidence of cerebrovascular accidents represents an emerging problem. The rise in risk factors such as lifestyle choices—smoking, poor nutrition, and metabolic diseases—poses a significant challenge for the global healthcare system. The female population, due to physiological conditions and iatrogenic risks, may be at a greater risk of developing ischemic accidents. In addition to these acquired conditions, life phases such as pregnancy or puerperium, and medical conditions like surgical treatments and hormone therapy, may elevate this risk. Methods: This narrative aims to assess the various risk factors specific to the female population and evaluate the appropriate management strategies, including anesthetic support. Anesthesia plays a crucial role in enabling pharmacological procedures, such as thrombolysis, or surgical procedures like thrombectomy, in the management of ischemic cerebrovascular events. Results: The review emphasizes the importance of early recognition of risk factors to ensure prompt diagnosis and the most appropriate treatment options for ischemic events. Anesthesia support has become essential for carrying out necessary medical interventions effectively. Choosing the right anesthesia technique for endovascular thrombectomy is particularly significant, requiring consideration of the patient’s characteristics, the timing of diagnosis, and the preferences of the interventional neuroradiologists. Conclusions: It is vital to identify risk factors in the female population early to facilitate timely diagnosis and optimize treatment outcomes. Anesthetic support plays a key role in ensuring that critical procedures, such as thrombolysis and thrombectomy, are carried out effectively. Tailoring anesthesia choices to the patient’s individual needs is critical for a successful intervention. Full article

Background: Crown lengthening (CL) in esthetic areas has become a versatile procedure with applications in many clinical situations. Knowledge concerning different periodontal phenotypes, and the supracrestal tissue attachment (STA)—former biological width—has allowed for a better understanding of surgical management, allowing for the individualization of surgical therapy. This review presented an individualized surgical approach to CL in esthetic areas based on evaluating the phenotype and current considerations about the STA, correlating them to suggestive surgical techniques. Methods: For an individualized surgical approach, it is primarily necessary to understand STA, including the relationship and distance between the cementoenamel junction (CEJ) and the bone crest (BC) and the position of the free gingival margin (FGM); secondarily, it is necessary to verify the periodontal phenotype to prepare surgical planning (gingivectomy or osseous resection/contouring). Three periodontal phenotypes are recognized, presenting different biological behaviors due to specific characteristics implicitly correlated to soft tissue management. Results: Then, after assessing the distance from the CEJ to the BC, the position of the FGM, and the periodontal phenotype, it is possible to individualize the treatment according to the phenotype. In cases of a thin and scalloped periodontium with delicate gingiva, there might be the presence of bone dehiscence, fenestration, and instability in the healing of the gingival margin, bringing extra attention to tissue manipulation and suggesting a minimally invasive technique (no flap). A partial-thickness flap is recommended for a thick and scalloped periodontium, keeping the periosteum adhered to the bone. For periodontium B (fibrous and dense gingiva and tissue resistant to injuries), the surgical approach recommended is an open full-thickness flap with osteotomy for horizontal and vertical bone volume removal. Then, observing first the specific parameters, such as the STA, CEJ, BC, FGM, and KTW, and then the characteristics of periodontal phenotypes, it is possible to determine the individualized surgical strategy and a reasonable surgical approach to tissue manipulation in clinical CL surgeries. Conclusions: The surgical approach must be defined according to individualized planning since several variables can influence the dynamics of the periodontal tissues. Full article

Background: Mandibular condylar fractures are among the most common fractures of the facial skeleton, and their surgical management remains a topic of considerable debate in maxillofacial trauma surgery. Numerous studies in the literature internationally have explored optimal treatment approaches, with a growing preference for open reduction and internal fixation (ORIF). While conservative treatment has traditionally been the standard for intra-articular fractures, recent research suggests that ORIF may also be appropriate for selected cases of these fractures. Methods: This study presents a 14-year review (2009–2023) of the authors’ experience in the surgical management of intra-articular condylar fractures. Data were collected on surgical techniques, early and late complications, clinical and radiological outcomes, and comparisons with conservative treatment. Results: The analysis included evaluations of both short-term and long-term outcomes following ORIF, identifying specific scenarios where ORIF demonstrated advantages over conservative management. Clinical and radiographic assessments provided valuable insights into patient recovery and functional outcomes, while complication rates were documented for both treatment methods. Conclusions: Findings indicate that ORIF can be a beneficial treatment option for intra-articular condylar fractures in select patient groups, offering improved outcomes in cases where conservative treatment may be insufficient. However, conservative management remains a valid approach when surgical risks exceed potential benefits. This study adds to the ongoing discussion, supporting a tailored approach that considers individual patient factors when choosing between ORIF and conservative treatment. Full article

Background: The gold standard treatment of acute cholecystitis is early laparoscopic cholecystectomy (LC), as indicated in the Tokyo Guidelines (TG). However, the definition of “early” is still unclear. In 2013, TG suggested surgical intervention within 72 h from the onset of the symptoms; however, according to the 2018 revision, LC must be performed as soon as possible, regardless of symptom onset. Therefore, the optimal timing for surgery is still debated. In order to avoid any complications, surgeons need to know all the surgical strategies for safety in case of a difficult cholecystectomy. Methods and Materials: Starting from January 2023 at Cittiglio Hospital (Italy), the following strategies were implemented: LC within 72 h from the onset of symptoms, systematic intraoperative use of indocyanine green fluorescence cholangiography, systematic identification of the Critical View of Safety (CVS), and subtotal cholecystectomy when the CVS was impossible to identify. We retrospectively analyzed a cohort of patients who underwent LC in our surgical department, subdividing them into two groups: Group 1 (G1) included patients operated on in 2022, and Group 2 (G2) included patients operated on in 2023. End points were length of stay and in-hospital postoperative complications, with particular interest in biliary duct injury. Results: Overall, 210 LC have been performed (97 in G1 and 113 in G2). After the introduction of the new safety strategy, the median length of stay (3 days in G1 vs. 2 in G2), BDI rate (2 in G1 vs. 0 in G2), and conversion rate to open procedure (5 in G1 vs. 1 in G2) were decreased. Conclusions: Our data are promising, highlighting that LC with the standardization of new safety strategies, especially in case of acute cholecystitis, immediately improves surgical outcomes in terms of length of stay and complications. Full article