OPERATIVE SESSION

Laparoscopic Cholecystectomy

Lana Al-Sabe, PGY-5, Chief Resident

General Surgery Department

Jordan University Hospital

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OUTLINE

Background
History
General Steps
Surgical Anatomy
B-SAFE zone
The SAGES Safe Cholecystectomy Program
Critical View of Safety
Bailout strategies for the difficult GB

PRESENTATION TITLE 2
 CHOLECYSTECTOMY TODAY
Cholecystectomy is the most common operation performed worldwide
(1,000,000 annually in the U.S).

The first laparoscopic cholecystectomy was performed In 1985 and quickly gained popularity &
became the gold standard operation for patients with symptomatic gallstones.

LC has advantages over OC in terms of wound infection, length of stay and pneumonia but it’s
associated with higher risk of BDI.

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 BILE DUCT INJURY (BDI)

• BDI is the most feared complication.

• 25% are identified intraoperatively
• The data in the literature is inconsistent but it’s reported to be in the range of 0.1-2.5% in
LC and 0.1% in OC
• Not much has changed in the last 15 years. Incidence seems to have plateaued (Even in
hospitals that apply the CVS)
• The most common reason for injuring the bile duct is due to the misidentification of normal
biliary anatomy.
• Routine intraoperative cholangiography does not decrease the incidence of bile duct injuries.

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 HISTORY

The first open cholecystectomy was performed by Karl Langenbuch in 1882

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 History

Eric Mühe performed the first laparoscopic cholecystectomy in Germany in 1985.

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 SURGICAL ANATOMY

• Hepatocystic triangle
• Calot’s triangle
• Cystic Plate
• Rouviere’s sulcus
• Liver segmen 4b
• Hartmann’s pouch
• Infundibulum
• Cystic lymph node of Lund

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STEPS IN LAPAROSCOPIC
CHOLECYSTECTOMY

• Access abdomen safely

• Position/port placement
• Retraction/ exposure
• Divide adhesions
• Dissection and identification of cystic structures
• Removal of the gallbladder
• Skin closure

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IDENTIFICATION OF
THE SAFE AREA
• Assess anatomy
• Assess difficulty
• Achieve orientation

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B-SAFE anatomical landmarks and R4U safety line

PRESENTATION TITLE 12
PRESENTATION TITLE 13
PRESENTATION TITLE 14
1 Line
2 Planes
4 Areas
4 Zones

PRESENTATION TITLE 15
AS zone is a green zone : A safe zone
for dissection as it contains the CT.

PS zone is an orange zone: A

potentially unsafe zone where
dissection could not be avoided
completely to achieve the CVS.

Both inferior zones are red zones and

totally unsafe.

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Demarcation of the superior safe area inferior
unsafe area by the R plane.

Demarcation of the anterior area posterior area

by the A plane.
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PS zone with
AS zone with white
black outline:
outline:
Surgeon should
Surgeon should
remain carful
start confine the
during dissection.
dissection here.

Inferior zones:
Dissection is totally
prohibited here.

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PROPER
RETRACTION
TO EXPOSE THE
HEPATOCYSTIC
TRIANGLE
The target area for dissection during LC.

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Hepatocystic triangle (blue):
Upper border is the inferior margin of liver.
Lateral border is the cystic duct and the neck of the gallbladder
Medial border is the CHD.

Calot’s triangle (yellow):

Upper border is the cystic artery.
Lateral border is the cystic duct.
Medial border is the CHD.

In the literature there is often no difference in the definition.

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The infundibulum is retracted superior-medially towards umbilical fissure/ left shoulder during
posterior dissection of the HCT.

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The infundibulum is retracted in right inferolateral direction during anterior dissection of the HCT

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TRACTION FORCE SHOULD BE MAINTAINED
SUFFICIENT ENOUGH TO OPEN UP THE HCT
AND FACILITATE DISSECTION.

HOWEVER

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 EXCESSIVE TRACTION CAN DISTORT THE
ANATOMY, ALIGN THE CYSTIC DUCT WITH THE
CBD,
WHICH MAY:

- Increase the risk of avulsion of the cystic

duct.

-Tear the cystic duct-CBD junction.

-May inure the diaphragm after accidental

slippage of fundal grasper.

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 CORRECT + ADEQUATE
RETRACTION TO OPEN UP THE HEPATOCYSTIC
TRIANGLE IN PREPARATION FOR DISSECTION.

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 THE SAGES SAFE
CHOLECYSTECTOMY
PROGRAM
2018

Mission:
To enhance a universal culture of safety for cholecystectomy to
minimize the risk of bile duct injury.

6 STEP
PROGRAM

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 SCP

1. Understand and apply the Critical view of safety (3 elements).

2. Perform intra-op TIME OUT before you clip, cut or transect.
3. Understand the potential for aberrant anatomy.
4. Make liberal use of IOC… or other IO methods
5. Recognize when the dissection enters the red zone and finish
the operation by a safe method other than cholecystectomy.
6. Get help!

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RULE 1:
THE CRITICAL
VIEW OF SAFETY
(A SAFE METHOD
OF DUCTAL
IDENTIFICATION)

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First described by Steven Strasberg in 1995.

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Three criteria are required to achieve the CVS:

• The hepatocystic triangle is cleared of fat and fibrous tissue but

necessary seeing the CBD and CHD.

• The lower one third of the gallbladder is separated from the liver
to expose the cystic plate.

• Two and only two tubular structures should be seen entering the
gallbladder.

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 WHAT IS THE EVIDENCE
THAT IT IS EFFECTIVE?

BDI have a low incidence but are common because of the large
number of cholecystectomies performed.

No RCT is possible!

Despite its widespread use, the scientific evidence supporting this te

chnique to prevent BDI is controversial.

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RULE 2:
INTRA-OP TIMEOUT
TO CONFIRM
THAT CVS HAS
BEEN CORRECTLY
ACHIEVED
Consider an Intra-operative Momentary Pause during
laparoscopic cholecystectomy prior to clipping, cutting or
transecting any ductal structures.
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 THE CYSTIC LYMPH NODE OF LUND
A LANDMARK OF SAFETY TO AVOID BDI

Also called the Calot or Mascagni node

Sentinel LN of the GB

Always lies lateral to the biliary tree and forms the medial end point of dissection
Efforts should be made to remain lateral to LN.

During difficult LC where achieving the CVS is impossible, the CLN may be the key
anatomic landmark

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 Retrograde dissection of the gallbladder off its liver bed by remaining close to the gallbladder

Proper retraction must be maintained by moving the neck of the gallbladder back and forth to optimize
visualization and maintain tension

Care should be taken to stay in the plane between the gallbladder and liver 36
bed
Cystic plate must be kept attached to the liver to avoid bleeding
and/or bile leakage from superficial subparenchymal duct

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RULE 3:
UNDERSTAND THE
POTENTIAL FOR
ABERRANT
ANATOMY

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 Cystic ductal variations, anatomical and pathological

A: Normal pattern with angular insertion

B: Cystic duct insertion in aberrant right hepatic duct
C: Cystic duct-parallel course. Cystic duct may be quiet long and may join the
common hepatic duct (CHD) near ampulla
D: Cystic ductal fusion with the CHD due to inflammation;
E: Short/effaced cystic duct due to impacted stone in the gallbladder neck.

In both situations (D and E), CHD would be at risk of injury during dissection
especially when the surgeon tries to expose the cystic duct-common bile duct
junction.
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RULE 4:
MAKE LIBERAL
USE OF IOC
AND OTHER INTRAOP
METHODS TO IMAGE
THE BILIARY TREE

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Uncertain anatomy
Suspected BDI
Selectively or routinely??
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RULE 5:
RECOGNIZE WHEN THE
DISSECTION IS
APPROACHING A ZONE OF
SIGNIFICANT RISK AND
HALT THE DISSECTION
BEFORE ENTERING THE
ZONE
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 WHEN TO STOP?
• Severe inflammation in the porta hepatis and neck of the gallbladder
• Unable to identify hepatocystic triangle
• Unable to achieve CVS
• Dissection is not progressing
• Excessive bleeding
• Extensive fibrosis

PRESENTATION TITLE 43
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RULE 6:
GET HELP FROM ANOTHER
SURGEON WHEN THE
DISSECTION IS DIFFICULT

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PREDICTORS
FOR THE
DIFFICULT GB

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PRESENTATION TITLE 47
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Example of intraoperative
prediction of difficult gallbladder
A: Moderate pericholecystic adhesions
B: Extensive pericholecystic adhesion

Gallbladder is not visualized in both of these situations

predicting difficult dissection.
 BAILOUT STRATEGIES FOR THE DIFFICULT
GALLBLADDER

Abort the procedure Convert to open

Subtotal Fundus first

Cholecystostomy tube Cholecystectomy Cholecystectomy

Ask for help from

Another surgeon

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PRESENTATION TITLE 52
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TAKE HOME MESSAGE

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 STAY ABOVE THE ROUVIER’S SULCUS.

STAY CLOSE TO THE GALLBLADDER WALL.

EMPOWER YOUR LEFT HAND FOR PROPER RETRACTION.

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THANK YOU.

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