Comprehensive

1. SAFE CHOLECYSTECTOMY
PRESENTER : DR BIBEK KARKI
MODERATOR: PROF PUNEET DHAR
AIIMS

2. REMEMBERING THE MASTERS

3. SAFE CHOLECYSTECTOMY
 Safe for the patient ( no bile duct/ hollow viscus/ vascular injury)
 Safe for the surgeon ( no or minimal scope for litigation)

4. ASPECTS OF SAFE CHOLECYSTECTOMY
Knowledge of relevant anatomy, landmarks and variations.
Mechanism in biliary/vascular injury
Identifications of various preoperative and intraoperative predictors of difficult
cholecystectomy
Proper GB retraction
Safe use of various energy devices
Understanding Critical view of safety
Use of intraoperative imaging techniques
Use of various bailout procedures

5. SURGICALLY RELEVANT ANATOMY
Be mindful of
 common anatomical variations
 Anatomical distortions due to pathological process

6. HEPATOCYSTIC TRIANGLE

7. HEPATOCYSTIC TRIANGLE : CLINICAL SIGNIFICANCE
 Target area for dissection during Laparoscopic cholecystectomy
 Cystic duct caudally
 Liver undersurface cranially
 CHD medially
 Contains cystic artery, portion of Rt hepatic artery, cystic lymph node, cystic LN, fibrofatty
connective tissues
 Hepatocystic triangle vs Calot’s triangle
 Cystic LN – often – superficial to cystic artery
Divide the artery to rt side of LN close to GB to avoid inj to Rt hepatic artery

8. CYSTIC PLATE
 Flat, ovoid fibrous sheet in GB bed.
 Imp to expose lower part of cystic plate while achieving CVS.
 CVS incomplete without this exposure
Anomalous duct may exit
Anomalous rt hepatic artery may enter
 Don’t breach the cystic plate while dissecting the GB off the
liver.
- Troublesome bleeding from liver parenchyma
- Inj to sub- vesical bile duct – post op bile leak.

9. BE VIGILANT IF IT IS A CHRONIC CHOLECYSTITIS

10. ROUVIERE’S SULCUS
 Present on the undersurface of Rt lobe of liver
 Running to rt of hepatic hilum
 Visible in 80 % cases.
 Contains Rt portal Portal pedicle or its branches
 Best seen when GB neck is retracted towards
umbilical fissure

11.  Indicates plane of CBD – orients surgeon in
difficulty
 All dissection – ventral & cephalad to the
line joining – roof of sulcus and base of
segment 4
 During post dissection of HC triangle– safe
to divide peritoneum ventral and cephalad
to sulcus.

12. SEGMENT 4 OF LIVER
 Identified between umbilical fissure and GB
Clinical Significance
 Base of segment 4 – fixed landmark
 Initial assessment of its size important
 Look at distance between umbilical fissure and GB
 Rule out congenital condition like ectopic Gb and segment 4 hypoplasia

13. ANATOMICAL VARIATIONS : VASCULAR ANOMALIES
Cystic artery
 Single and arises from RHA ( 79%)
 Traverses the hepatocystic triangle
 Supplies GB --- through 2 br’s-
superf and deep
 Variation in origin, no and course

14.  If short cystic artery– Mistakely clipping and division of RHA
 Keep the dissection of artery close to GB on Rt side of cystic LN
-- presents inj to RHA
 Cystic art --- from GDA or LHA-- Doesn’t pass through HC triangle
--- Can’t be localized during dissection in this triangle

15. VARIATION OF RT HEPATIC ARTERY
 RHA usually passes behind the CHD before entering HC triangle.
 Aberrant RHA ( replaced or accessory)
 Replaced RHA – lies on rt side of BD– Travels close to cystic duct and GB---
joins rt pedicle high up in HC triangle.

17. ABERRANT RHA: BE CAUTIOUS
 During dissection in HC triangle–
replaced RHA– mimic large cystic art
– risk of inj
 RHA – take a tortous course within
HC triangle
 May lie close to GB and cystic duct-
before giving off cystic art

18. BILE DUCT ANOMALIES: CYSTIC DUCT AND RHD ANOMALIES
Cystic Duct
Clinical Significance
Length, course and joining pattern with CHD –variable
If cystic duct not apparent during LD, either it is short or
may be effaced by stone or Mirizzi synd is present.
Be careful!! – may have to resort to bail out techniques
If two cystic duct are visible– don’t hurry to label
Clarify anatomy( use IOC) as may be CHD and CBD with
short or effaced cystic duct

19.  Cystic duct diameter may be increased to 5 mm ----d/t passage of stone
--may be confused with CBD.
 If unable to completely occlude the cystic duct with a medium size clip
--- Raise the suspicion of CBD
Clearify with proper display of CVS or Intraop imaging
 Anomalous insertion of Rt sectional duct -- when cystic duct joins it
Risk of inj of sectional duct

20. PREDICTORS OF DIFFICULT CHOLECYSTECTOMY:
AN ASTUTE SURGEON PLANS CHOLECYSTECTOMY IN OPD NOT OR
Intraoperative
 Small shrunken GB not visualized
on initial exploration
 Liver edge retracted with fissure/
depression/puckering near fundus
 Firm/cirrhotic liver

21. IS ULTRASONOGRAPHY ENOUGH?
 For diagnosing gallstones --- YES
 If suspecting CBD ---- do an MRCP
 CT warranted if thick walled GB
--- suspicion of Ca GB
--- Complications of GB stones
 EUS
Better than US abd to pick up CBD
stone esp in distal CBD

22. INTRAOP PREDICTORS CONT’D

23. UNDERSTANDING AND EXECUTION OF CORRECT TECHNIQUE
Basic essential steps
 GB retraction
 Dissection in HC triangle to achieve CVS
 Clipping and division of cystic duct and artery
 Dissection of GB from its bed

26. CORRECT EXPOSURE OF HC TRIANGLE FOR DISSECTION
 Adequate retraction of Gb in
proper direction
 Fundus towards the Rt shoulder
of pt
 Infundibulum infero laterally
towards rt side of pt
 Visualization of cystic LN
 Anatomical landmark for cystic
art

27. WHY INFUNDIBULAR RETRACTION NEEDED?
 When retraction made towards umbilical fissure
 Visualization of Post HC triangle
If not properly retracted
 CBD pulled up in RUQ– parallel alignment of
CBD and cystic duct
 CBD may be mistaken for cystic duct

28. DIFFICULTY IN GRASPING AND RETRACTING FUNDUS
 As in tensely distended GB such as acute
cholecystitis, mucocele, thick walled GB
2 Options
 GB – decompression by aspiration
 Take stay sutures
Large stone in Hartmann’s pouch
--- dislodge the stone
Use angled laparoscope (30/45deg)
--- better visualization of surgical field
from diff angles

29. SAFE ZONE OF DISSECTION:
BE CEPHALAD TO THE SAFETY LINE

30. CONCEPT OF TIME OUT:
TAKE YOUR TIME, DON’T PANIC
Dictum: B- SAFE to be safe
To be safe – use B- SAFE
Aim: Reorientation/ reassessment
What to do: Stop – Wait- Reassess - Act
What to see: B- SAFE
When to see
1. Before beginning dissection in hepatocystic
triangle
2. Whenever there is any doubt about anatomy
3.After achieving CVS and before dividing cystic
duct and cystic artery ( define, decide and then
divide)

31. JUDICIOUS USE OF ENERGY SOURCES
 Monopolar, bipolar cautery and Ultrasonic devices
 If monopolar cautery is used
keep at low setting ( <30 W) to avoid arcing of current to bile duct
divide small amount of tissue at a time—to avoid inj to deeper structures by heel of hook
cautery
avoid blind use of cautery in case of brisk bleeding
use intermittent short burst of current

32. CRITICAL VIEW OF SAFETY
 Hepatocystic triangle is cleared off fatty and
fibrous tissue
 Lower third of GB is separated from the liver to
expose cystic plate.
 Two and only two structures should be seen
entering the GB

34. CONCEPT OF CRITICAL VIEW OF SAFETY
 Don’t confuse
--cystic duct with CBD and aberrant Rt sectional duct
--cystic artery with RHA
 Final view achieved
 After thorough dissection of HC triangle
 To delineate cystic duct and cystic artery
 Before clipping and dividing

35. REMEMBER WHILE ACHIEVING CVS
 Aim shouldn’t be to expose cystic –
CBD junction
 Expose lower third of cystic plate
 Allows safe identification of
abnormal third structure
 Circumferential visualization of
cystic duct and artery--- (doublet
View)
 Once achieved, stop and reconfirm
Why achieving CVS is so valuable
 Most effective method of preventing
BDI
 If difficulty in achieving CVS--- risk
of bilivascular inj.

36. REMEMBERING ERROR TRAPS
Infundibular Technique
 Identification of cystic duct
-- appearance of infundibular- cystic duct
junction
 May be misleading at times
-- Cystic duct fused with CHD
-- Cystic duct very short
-- Cystic duct effaced with large stone in
infundibulum
Fundus first( dome down)
technique
 Technical challenge in handling GB
 Tends to twist once separately completely from
liver
 Difficulty in retracting liver

37. HANDLING DIFFICULT SITUATION
A SAFE SURGEON ON ANY GIVEN DAY IS BETTER THAN FAST SURGEON
Identifying red flags
Red flags
More than 2 tubular structures entering GB
Unusually large presumed cystic artery
Large arterial pulsation present behind presumed cystic duct( may be
CHD/BD)
Medium- large clips failing to occlude cystic ductal lumen
Large ductal structure that can be traced behind duodenum ( = CBD)
Excess fibrofatty/ lymphatic tissue noted around presumed cystic duct( =
CHD/BD)
Bile leak seen within intact GB
Bleeding requiring BT

38. CALL FOR HELP/ SECOND OPINION
NEVER CONSIDER THIS AS AN SURGICAL EPTITUDE
Never hesitate to take second opinion if
 Difficult GB
 Unusual Anatomy
 Difficult dissection

39. PLACEMENT OF DRAIN: IS IT ESSENTIAL?
 Not advised routinely
Put one if
 If incomplete/ inadequate hemostasis to monitor bleeding in postop period
 Unsatisfactory cystic duct stump eg wide cystic duct
 Partial cholecystectomy

40. SAGES RECOMMENDATION
 CVS over other methods for mitigating risk of BDI in LC
Recommended for identification of cystic artery and cystic duct
However, no direct comparative evidence
 Fundus first technique vs subtotal cholecystectomy when CVS not achieved
Subtotal cholecystectomy over total cholecystectomy by fundus first technique( exp opinion)
However, no direct comparative evidence
 Infrared biliary imaging vs IOC for limiting risk and severity of BDI
No recommendation made as no evidence comparing the two
 Conversion of lap to open vs no conversion for BDI
No recommendation/ evidence

41. SAGES RECOMMENDATION CONT’D
 Complexity Risk stratification
For acute chole – use Tokyo Guidelines 18, AAST 18 classificn for grading and pt management
During surg --- consider different factors of difficult chole
 Timing of Cholecystectomy in AC
Mild cholecystitis--- can do LC within 72 hrs.
Mod to Severe cholecystitis--- insufficient evidence
 Experience of Surgeon in difficult cholecystectomy
Advocate for experienced surgeon over less experienced one
 If BDI occurs in OR or early postop period
Referral to experienced hepatobilary surgeons with experience of reconstruction

42. USE OF INTRAOP IMAGING
Intraoperative Cholangiography
 Safe technique for assessment of
--biliary anatomy, identification and assessment of extent of biliary inj
 Detects asymptomatic CBD stones
 Challenge: Difficulty in ductal cannulation
 Can prevent inj d/t anamolous anatomy
 Routinely vs Selectively ???
 SAGES Recommendation
--- Be liberal if it is an acute cholecystitis
--- If uncertain biliary anatomy or suspicion of BDI

43. ROLE OF ICG
 Involved the excretion of fluorescent
indocyanine green (ICG) into the bile
 Near infrared fluorescence cholangiography
(NIRF- C)
--- Safe, effective method for identifying
extrahepatic biliary anatomy
 Non invasive method of real time
 Preop - dye --- Injected IV---- Bound to PP–
taken by hepatocytes– excreted unaltered in bile
 Laser on laparoscope– excites ICG --- infrared
fluorescence– captured by an image filter on
laparoscope

44. LAPAROSCOPIC US
 Non invasive, shorter procedure time
 Diagnoses CBD stone
 Less accurate for assessment of intrapancreatic and intrahepatic
part of biliary system

45. BAILOUT TECHNIQUES
SAFETY OVER COMPLETION OF SURGERY
Perform alternative procedure rather than being tempted to complete difficult cholecystectomy
Bailout
Abort the procedure together
Convert to an open procedure
Tube cholecystotomy
Subtotal cholecystectomy ( if frozen, fibrotic or scarred GB)
Fundus first cholecystectomy

46. DOCUMENTATION
YOU NEED TO BE SAFE BESIDES THE PATIENT
 Vigilance during writing operative notes
 Describe the measures taken to achieve CVS, preferably with photo/video.
 Inadequate documentation – malpractice litigation
 Inform what had happened, document what had happened and document
that you had documented.

47. CONCLUSION