When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy

Abstract

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.

Keywords: acute cholecystitis; anatomical landmarks; bailout surgery; bile duct injury; critical view of safety; laparoscopic cholecystectomy.

Figure 1

Intraoperative depiction of Rouviere’s sulcus (circumscribed by the red dotted line).A theoretical construct derived from RS is the R4U line concept introduced by Gupta [40]. The area above the plane that crosses through RS under the fourth segment of the liver and towards the umbilical ligament should be safe for dissection.

Figure 2

Depiction of the R4U plane (blue) and safety zones (safe plane in green, unsafe plane in red).

Figure 3

Zonal demarcation for safe dissection according to Gupta with four zones: AS—antero-superior zone, AI—antero-inferior zone, PS—postero-superior zone, PI—postero-inferior zone. Safe zones coloured in green, unsafe zones coloured in red.

Figure 4

Intraoperative view of the two subserosal layers. Inner and outer layers pointed out by arrows.

Figure 5

Schematic representation of the two subserosal layers modified after Honda. The arrows define the semi-circular area for the peritoneal incision and dissection of the outer SS layer that allows the visualization of the inner SS layer.

Figure 6

Schematic representation of Calot’s (black line) and Bode Rocko (red line) triangles.

Figure 7

Depiction of traction direction (arrows) during exposure of Calot’s triangle with emphasis on one of the vascular structures(coloured in red).

Figure 8

Depictions of the variations in the insertion of the cystic duct—modified after Gunduz: H—high insertion, M—medium insertion, L—low insertion. A—anterior, L—lateral, P—posterior, M—medial.

Figure 9

Intraoperative view of the common bile duct in conventional (left) and NIR light (right)—personal collection. C—cystic duct, CBD—common bile duct.

Figure 10

Sutherland’s B-SAFE acronym. B—biliary structures and base of segment 4, S—Rouviere’ssulcus, A—hepatic artery, F—fisuraumbilicalis, E—enteric structure. White line: R4U line.

Figure 11

Algorithm for difficult LC based on Mintzberg’s perspectives on strategic thinking. The algorithm flow for successful identification (green) vs unsuccesful identification (red) of the anatomical landmarks.

Figure 12

Mnemonic map:principles of safety in LC; (A–D)—represent successive steps of the mnemonic map.