# The Hanging Strap Method: A Safe and Easy-to-Use Surgical Technique for Surgeons-in-Training Performing Difficult Laparoscopic Cholecystectomy

## TL;DR

This paper introduces a new surgical technique called the hanging strap method that helps trainee surgeons safely perform a difficult type of gallbladder surgery.

## Contribution

The novel contribution is a safe and user-friendly surgical technique for trainees performing complex laparoscopic cholecystectomy.

## Key findings

- The hanging strap method was used more frequently by surgeons-in-training with less experience.
- There were no bile duct injuries, postoperative bile leaks, or operative deaths in either group.
- The method did not increase operative time or blood loss compared to traditional techniques.

## Abstract

Introduction

Surgeons-in-training (SIT) perform laparoscopic cholecystectomy (LC); however, it is challenging to complete the procedure safely in difficult cases. We present a surgical technique during difficult LC, which we named the hanging strap method.

Methods

We retrospectively compared the perioperative outcomes between patients undergoing difficult LC with the hanging strap method (HANGS, n = 34), and patients undergoing difficult LC without the hanging strap method (non-HANGS, n = 56) from 2022 and 2024. Difficult LC was defined as cases classified as more than grade II cholecystitis by the Tokyo Guidelines 18 and cases when LC was undergoing over five days after the onset of cholecystitis.

Results

The proportion of SIT with post-graduate year (PGY) ≤ 7 was significantly higher in the HANGS group than in the non-HANGS group (82.4% vs. 33.9%, P < 0.001). The overall rate of bile duct injury (BDI), postoperative bile leakage and operative mortality were zero in the whole cohort. There were no significant differences between the HANGS and non-HANGS groups in background characteristics, operative time (122 min vs. 132 min, P = 0.830) and surgical blood loss (14 mL vs. 24 mL, P = 0.533).

Conclusions

Our findings suggested that the hanging strap method is safe and easy to use for difficult LC. We recommend that the current method be selected as one of the surgical techniques for SIT when performing difficult LC.