Using a standardized method for laparoscopic cholecystectomy to create a concept operation-specific checklist

Abstract

Objectives: Prevalences of bile duct injury (BDI) following laparoscopic cholecystectomy (LC) remain unacceptably high. There is no standardized method for performing an LC. This study aims to describe a standardized technique for LC that will allow for the development of a concept LC checklist, the use of which, it is hoped, will decrease the prevalence of BDI.

Methods: A standardized method for LC was developed based on previously published expert analysis supplemented by video error analysis of operations in which BDI occurred. Established checklist methodology was then used to construct an LC-specific concept checklist.

Results: A five-step technique for the safe establishment of the critical view was created to guide the development of the checklist. The five steps are: (i) confirm the gallbladder lies in the hepatic principal plane and is retracted to the 10 o'clock position; (ii) confirm Hartmann's pouch is lifted up and toward the segment IV pedicle; (iii) identify Rouvière's sulcus; (iv) confirm the release of the posterior leaf of the peritoneum covering the hepatobiliary triangle, and (v) confirm the critical view with or without intraoperative cholangiography.

Conclusions: A standardized approach to LC would allow for the creation of an LC-specific checklist that has the potential to lower the prevalence of BDI.

Figure 1

Landmarks of the hepatobiliary triangle. The grey area shows the hepatobiliary triangle, bounded by the common hepatic duct, cystic duct and inferior border of the liver. The smaller dark grey area shows Calot's triangle, bounded by the cystic duct and cystic artery and common hepatic duct

Figure 2

(a) Retracting the gallbladder to the 10 o'clock position assists in the eventual exposure of the posterior peritoneum covering the hepatobiliary triangle. (b) If the gallbladder is retracted cephalward and medially (12 o'clock), the surgeon is obliged to dissect the cystic duct front on

Figure 3

Hartmann's pouch should be lifted up and across toward the segment IV pedicle to maximize the exposure of the posterior peritoneum of the hepatobiliary triangle to the operating surgeon

Figure 4

(a) Rouvière's sulcus (arrow) should be used as an extrabiliary landmark to guide the level of safe initial dissection [green in (b)]. (b) The imaginary line drawn between the sulcus and the base of segment IV indicates the level below which dissection should not occur (red). (Modified with permission from Hugh et al.

Figure 5

The posterior peritoneum of the hepatobiliary triangle should be released and dissection continued until the posterior surface of the cystic artery can be seen (arrow)

Figure 6

The critical view should be confirmed with the assistant. In these photographs, the gallbladder has been dissected off the cystic plate and only the dissected cystic artery and duct are visible within the hepatobiliary triangle

Figure 7

If intraoperative cholangiography (IOC) is performed, critical analysis using the IOC checklist should be applied. (a) This should confirm the presence of three hepatic ducts (right anterior, right posterior, left main) (a1), the filling of the duodenum (a2), the absence of filling defects (a3), and the presence of a cystic duct as indicated by the presence of spiral valves. In this cholangiogram the anatomy appears complete, but note the absence of the cystic duct and the cannulation of the common bile duct (a4), resulting in significant bile duct injury. (b) If present, the spiral valves in the cystic duct (arrow) may provide useful confirmation that the correct duct has been cannulated

Figure 8

Proposed format for a laparoscopic cholecystectomy checklist