Editorial
Critical Strategies for Safe Laparoscopic Cholecystectomy
Bulent Kaya* and Nuriye Esen Bulut
Department of General Surgery, Health Science University Fatih Sultan Mehmet Training and Resarch Hospital,
Turkey
*Corresponding author: Bulent Kaya, Department of General Surgery, Health Science University Fatih Sultan Mehmet Training and Resarch Hospital, Atasehir, Istanbul, Turkey
Published: 30 Nov, 2017
Cite this article as: Kaya B, Bulut NE. Critical Strategies for
Safe Laparoscopic Cholecystectomy.
Clin Surg. 2017; 2: 1779.
Editorial
Laparoscopic Cholecystectomy (LC) is one of the most commonly performed operation
world wide. Before the routine use of laparoscopy, the incidence of Major biliary injuries were
approximately 0.2% in open cholecystectomy [1]. After the acceptance of LC as a gold standart
surgical approach for cholelithiasis, the incidence of biliary injuries were doubled. Many factors are
related with such injuries including obesity, cholecystitis, malegender, variations in anatomy e.t.c.
The most common cause of biliary injury is misidentification of important anatomical structures.
Usually, overtraction of infundibulum is associated with aligment of common bile duct to cystic
duct. Thus common bile dust is clipped as a cystic duct and cut. After continuing dissection lateral
to the common bile duct, common hepatic duct is also clipped in hilum of the liver. Right hepatic
artery may also be injuried. This is the classical mechanism of major biliary injury.
Biliary injuries during LC is still an important problem and many attemps were performed
to decrease these complications. Bile leaks and peritonitis, bile duct strictures with cholangitis,
sepsis, cirrhosis, liver failure are all consequences of such injuries. Mortality rate is high with these
complications. Anational survey from Italy detected an incidence of 0.42% of major bile injuries
during LC in 56 591 patients. The risk was higher in patients with cholecystitis and low-volume
centers [2]. A safe cholecystectomy technique is particularly important. Strasberg in 1995, first
suggested a surgical technique called the “Critical View of Safety” (CVS), to decrease the risk of bile
duct injuries [3]. In fact, a correct CVS should have three successful steps:
1. Meticulous dissection of the Calot’s triangle from all fatty and fibrous tissue.
2. Lowest part of gallbladder should be separated from the cystic plate, which allows the
visualisation of posterior liver bed.
3. Dissection and identification of only two structures (cysticduct, cysticartery) entering the
gallbladder. Most of the time exploration of common bile duct is not mandatory.
CVS technique was used succesfully in many centers. Avgerinos et al. [4] reported on 1,046
patients having laparoscopic cholecystectomy. A total of 998 patients were operated with CVS
technique. The conversion rate was 2.7%. There were 5 minor bile leaks without any major bile
duct injuries [4]. In our clinic, CVS technique is standart part of LC were ported 120 cases without
any biliary complications with CVS technique [5]. As a medico-legal issue basic parts of CVS
should be added to operation notes. The photographic documentation of CVS is also encouraged.
Anybiliaryinjuryandrepairshouldalso be explained in operation notes. Although CVS is an useful
technique in LC, some other suggestions and technical notes can be found in literature. SAGES
(Society of American Gastrointestinal and Endoscopic Surgeons) introduced a safe cholecystectomy
program. To minimize the biliary injuries 6 strategies were suggested:
1. Critical View of Safety (CVS) method should be used including 3 basics approach; Calot’s
triangle should be cleared of fat and fibrous tissue, the lower one third of the gallbladder is dissected
from the liver to expose the all anatomical structures and cystic duct and artery should be isolated.
2. Intra-operative time-out prior to clipping, cutting or transecting any ductal structures is
advised.
3. Variations in anatomy should be considered in all cases.
4. Surgeon should use cholangiography or other instrument for demonstrating biliary
anatomy.
5. In case of difficulty to expose biliary anatomy alternatives urgical techniques such as
partial cholecystectomy, cholecystostomy tube placement or conversion to an open procedure can be beneficial.
6. Consultation with an another surgeon in difficult cases may
be helpful.
As a relatively high volume center, we can add some practical
suggestions for safe cholecystectomy. The essential part of safe LC is
absolute identification of anatomical structures before any surgical
intervention including usage of electrocautery, clipping and cutting.
The high quality image producing laparoscopic equipments were
advised with 30° camera. Electrocautery should be used minimally
in Calot’s triangle and structures near to the common bile duct.
Dissection should begin near the neck of the gallbladder and proceed
from the lateral to the medial direction, always staying close to the
gallbladder. Clips should be placed close to the gallbladder for cystic
duct or cystic artery. A wide, inflamed cystic duct can be closed
with ligation, simple sutures or staples. All structures should be
clipped or cut only after completely (360-degree) encircled. Routine
intraoperative cholangiography is not suggested. It should be
considered especially in case of uncertain biliary anatomy, suspicious
or obvious injury of the bile ducts. The surgeon should be familiar
with technique and interpretation of intraoperative cholangiography.
Safe cholecystectomy is an important issue. CVS technique with other
major suggestions mentioned in this manuscript can minimize bile
duct injuries during LC.
References
- Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparo-scopic cholecystectomy: a prospective nationwide series. J Am Coll Surg. 1997;184(6):571-8.
- Nuzzo G, Giuliante F, Giovannini I, Ardito F, D’Acapito F, Vellone M, et al.Bile duct injury during laparoscopic cholecystectomy: Results of an Italian national survey on 56 591 cholecystectomies.Arch Surg. 2005;140(10):986–92.
- Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101–25.
- Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic cholecystectomies in a single surgical unit using the "critical view of safety"technique. J Gastrointest Surg. 2009;13(3):498–503.
- Kaya B, Fersahoglu MM, Kilic F, Onur E, Memisoglu K. Importance of Critical view of safety in laparoscopic cholecystectomy: a survey of 120 serial patients, with no incidence of complications. Ann Hepatobiliary Pancreat Surg. 2017;21(1):17-20.