THE CONCEPT OF CVS
The requirements of the critical view of safety are:
1. Clearance of the hepatocystic triangle of all adipose and fibrous tissue.
2. Removal of the gallbladder from the bottom one-third of the cystic plate of the liver.
3. Two and only two structures are seen entering the gallbladder: the cystic duct and cystic artery.
The hepatocystic triangle is the target area of dissection to perform a safe cholecystectomy.
It is bound
-medially by the common hepatic duct
-laterally by the cystic duct
-and superiorly by the under-surface of the liver
Scott-Conner CE, Hall TJ. Variant arterial anatomy in laparoscopic cholecystectomy. Am J Surg. 1992Jun;163(6):590–2.
MECHANISM OF CLASSIC INJURY
After dissection of the apparent hepatocystic triangle, the two structures (artery and duct) entering the gallbladder are identified.
Davidoff,A. M., T. N. Pappas, E. A. Murray, D. J. Hilleren, R.D. Johnson, M. E. Baker, G. E. Newman, P. B. Cotton, and W. C. Meyers. “Mechanisms of Major Biliary Injury during Laparoscopic Cholecystectomy.” Annalsof Surgery 215, no. 3 (March 1992): 196–202.
IMPORTANCE OF THE SECOND AND THIRD CRITERIA OF CVS
The injury can be avoided by ensuring that only two structures are seen entering/ leaving the gallbladder.
The lower third of the cystic plate must be exposed both anteriorly and posteriorly before any structure is clipped or divided.
“Error Traps and Vasculo-Biliary Injury in Laparoscopic and Open Cholecystectomy.” Strasberg, Steven M. Journal of Hepato-Biliary-Pancreatic Surgery 15,no. 3 (2008): 284–92.
THE CYSTIC DUCT
The dissection and ligation of the cystic duct should take place near its junction with the gallbladder. The junction with the bile duct should not be dissected to avoid injury to the bile duct.
The cystic duct can join the bile duct
A. at an angle (~75%)
B. running parallel to the bile duct for a distance (~20%)
C. to the left of the bile duct (~5%)
a. In the infundibular approach, a characteristic “flare” or a funnel like shape is used to identify the junction of the cystic duct and the gallbladder.
b. In patients in whom the cystic duct has been shortened by a distended gallbladder neck, this approach can result in misidentification of the CBD for the cystic duct.
THE CYSTIC ARTERY
The cystic node usually lies just superficial to the position of the cystic artery in the cystic triangle.
If the node cannot be dissected off the cystic artery, the artery should be clipped to the right of the node to avoid injuring the RHA.
Cystic artery variants
A. Single artery dividing into one superficial and one deep branch near the gallbladder wall- most common (~72%).
b. Multiple arteries in the hepatocystic triangle , due to early branching (~22%).
c. Cystic artery may be caudal to the cystic duct, especially when arising from an anomalous RHA (~6%).
The RHA can sometimes take a tortuous course called the “caterpillar turn or Moynihan’s hump” and may be prone for injury in the hepatocystic triangle.
Scott-Conner CE, Hall TJ. Variant arterial anatomy in laparoscopic cholecystectomy. Am J Surg. 1992Jun;163(6):590–2.
FerzliG, TimoneyM, Nazir S, SwedlerD, Fingerhut A. Importance of the node of Calot in gallbladder neck dissection: an important landmark in the standardized approach to the laparoscopic cholecystectomy. J LaparoendoscAdv SurgTech A. 2015 Jan;25(1):28–32.
RETRACTION OF THE GALLBLADDER
The fundus of the gallbladder should be retracted towards the patient’s right shoulder (upwards and towards the right).
A. The infundibulum should be retracted downwards and laterally – so that the cystic duct- CHD junction forms a right angle.
B. Improper retraction can align the CBD and the cystic duct in a straight line-potentiating bile duct injury.
For posterior dissection, the infundibulum is retracted medially and upwards towards the round ligament.
Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy. Am J Surg. 1991 Jul;162(1):71–6.
LANDMARKS FOR DISSECTION
The illustration demonstrates the relationship between the plane of the bile ducts entering the liver and the anatomical landmarks.
The Rouviere’s Sulcus, seen in more than 75% of patients, serves as a landmark for posterior dissection of the hepatocystic triangle. It contains the right posterior portal pedicle and marks the level of the hilar plate.
Hugh TB, Kelly MD, Mekisic A. Rouvière’s sulcus: a useful landmark in laparoscopic cholecystectomy. Br J Surg. 1997 Sep;84(9):1253–4.
Anteriorly the base of the quadrate lobe(segment IV) marks the level of the hilar plate.
The anterior peritoneum can be safely opened superior to the plane of this line.
Any dissection done above the level of a line drawn joining the roof of the Rouviere’s sulcus and the base of segment 4 (R4U line) is safe.
Rajkomar K, Bowman M, Rodgers M, Koea JB. Quadrate lobe: a reliable landmark for bile duct anatomy during laparoscopic cholecystectomy. ANZ J Surg.2016 Jul;86(7–8):560–2.
PLANES OF DISSECTION
The subserosal layer of the gallbladder wall can be divided into
•An inner layer, which consists of abundant vasculature and some fibrous tissue, and
•An outer layer, which consists of abundant fat tissue
The plane of dissection lies between these two layers. The ss-o (the fatty layer) is stripped off the ss-I (has a shiny bluish green appearance).
A. The plane of dissection is between the cystic plate and the gallbladder wall.
Dissection deeper to the cystic plate will lead to bleeding from the liver bed and possible injury to the sub-vesicle bile ducts.
B. The lower third of the cystic plate should be cleared to establish the CVS.
C. After the cystic structures are divided, the gallbladder is removed from the liver bed dissecting between the GB wall and the cystic duct.
Honda G, Iwanaga T, Kurata M, Watanabe F, Satoh H, Iwasaki K. The critical view of safety in laparoscopic cholecystectomy is optimized by exposing the inner layer of the subserosal layer. J Hepatobiliary Pancreat Surg. 2009;16(4):445–9.
ROADMAP FOR CHOLECYSTECTOMY
The most important step is the decision to convert from a standard cholecystectomy technique to a damage control approach, by identifying situations where attempts at further dissection in the cystic triangle, however careful, will be dangerous.
Strasberg SM. A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review. J Hepatobiliary PancreatSci. 2019 Apr;26(4):123–7.
FUNDUS FIRST TECHNIQUE (DOME DOWN/ RETROGRADE)
While conventionally, The gallbladder is separated from the cystic plate in an antegrade fashion, it can also be separated in a retrograde fashion. As the cystic artery is not ligated before separation, more bleeding from the gallbladder bed is encountered with this technique. A small piece of peritoneum/ GB wall at the fundus is left behind for ease of retraction of the liver.
A. Caution must be employed to stay on the wall of the gallbladder. Any deviation from this plain can result in injury to the hilar structures.
B. Endoloops are used for ligation of the cystic duct with the artery en-masse.
In acute cholecystitis, the gallbladder and along with it the cystic plate is shortened, and the borders are indistinct. The hepatocystic triangle gets distorted and obscured.
The CVS is only 1 part of COSIC(culture of safety in cholecystectomy)- a reliable bail-out operation is another key component of safety. When CVS cannot be achieved, a subtotal cholecystectomy remains the best bail-out option.
The anterior wall is opened, and the gallstones are removed.
The posterior wall is separated and divided from the liver bed till a few centimeters above the R4U line.
The remnant GallBladder is dealt with in two different ways:
§Fenestrating subtotal cholecystectomy
§Reconstituting subtotal cholecystectomy
Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ. Subtotal Cholecystectomy-“Fenestrating” vs “Reconstituting” Subtypesand the Prevention of Bile Duct Injury: Definition of the Optimal Procedurein Difficult Operative Conditions. J Am Coll Surg. 2016 Jan;222(1):89–96.
The cystic duct opening, which can often be visualized from the internal aspect through the angled laparoscope, can be suture ligated from the inside of the remnant infundibulum.
Usually, the inflammation makes this difficult.
The mucosal surface of the remnant wall of the gallbladder is cauterized.
A drain is placed at the infundibulum directly above the cystic duct and brought through the skin at the laparoscopic port site directly above.
The biggest drawback of this approach is the high post operative bile leak- these fistulas seem to resolve spontaneously in most cases. But it is safer than having a bile duct injury.
Dissanaike S. AStep-by-Step Guide to Laparoscopic Subtotal Fenestrating Cholecystectomy: A Damage Control Approach to the Difficult Gallbladder. J AmColl Surg. 2016;223(2):e15-18.
While in the fenestrating type the remnant is trimmed down to the bare minimum, in the reconstituting type a larger remnant is left behind.
The remnant is suture closed.
While the postoperative bile leak is less, gallbladder remnants may become symptomatic years after subtotal cholecystectomy.
Fujiwara S, Kaino K, Iseya K, Koyamada N. Laparoscopic subtotalcholecystectomy for difficult cases of acute cholecystitis: a simple techniqueusing barbed sutures. Surg Case Rep. 2020 Sep 29;6(1):238.
1.Abdalla S, Pierre S, Ellis H. Calot’s triangle. Clin Anat. 2013May;26(4):493–501.
2.Bf S, LmB, MjP. The Difficult Gallbladder: A Safe Approach to a Dangerous Problem. J LaparoendoscAdv SurgTech A. 2017 Mar 28;27(6):571–8.
3.Coco D, Leanza S. Laparoscopic Cholecystectomy (LC): Toward Zero Error. OpenAccess Macedonian Journal of Medical Sciences. 2020 May 28;8(F):52–7.
4.Connor SJ, Perry W, Nathanson L, Hugh TB, Hugh TJ. Using a standardized methodfor laparoscopic cholecystectomy to create a concept operation-specificchecklist. HPB (Oxford). 2014 May;16(5):422–9.
5.Davidoff AM, Pappas TN, Murray EA, HillerenDJ, Johnson RD, Baker ME, et al. Mechanisms of major biliary injury duringlaparoscopic cholecystectomy. Ann Surg. 1992 Mar;215(3):196–202.
6.DissanaikeS. A Step-by-Step Guide to Laparoscopic Subtotal FenestratingCholecystectomy: A Damage Control Approach to the Difficult Gallbladder. J AmColl Surg. 2016;223(2):e15-18.
7.FerzliG, TimoneyM, Nazir S, SwedlerD, Fingerhut A. Importance of the node of Calot in gallbladder neck dissection:an important landmark in the standardized approach to the laparoscopiccholecystectomy. J LaparoendoscAdv SurgTech A. 2015 Jan;25(1):28–32.
8.Fujiwara S, KainoK, IseyaK, KoyamadaN. Laparoscopic subtotal cholecystectomy for difficult cases of acutecholecystitis: a simple technique using barbed sutures. SurgCase Rep. 2020 Sep 29;6(1):238.
9.Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universalculture of safety in cholecystectomy. World J GastrointestSurg. 2019 Feb 27;11(2):62–84.
10.Honda G, Iwanaga T, KurataM, Watanabe F, Satoh H, Iwasaki K. The critical view of safety in laparoscopiccholecystectomy is optimized by exposing the inner layer of the subserosallayer. J Hepatobiliary PancreatSurg. 2009;16(4):445–9.
11.Hugh TB, Kelly MD, Li B. Laparoscopic anatomy of the cystic artery. Am J Surg.1992 Jun;163(6):593–5.
12.Hugh TB, Kelly MD, MekisicA. Rouvière’ssulcus: a useful landmark in laparoscopic cholecystectomy. Br J Surg. 1997Sep;84(9):1253–4.
13.Hugh TB. New strategies to prevent laparoscopic bile duct injury–surgeons canlearn from pilots. Surgery. 2002 Nov;132(5):826–35.
14.Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy.Am J Surg. 1991 Jul;162(1):71–6.
15.Jung YK, Kwon YJ, Choi D, Lee and KG. What is the Safe Training to Educate theLaparoscopic Cholecystectomy for Surgical Residents in Early Learning Curve?Journal of Minimally Invasive Surgery. 2016 Jun 15;19(2):70–4.
16.Kelly MD. Laparoscopic retrograde (fundus first) cholecystectomy. BMC Surg.2009 Dec 11;9:19.
17.KunasaniR, Kohli H. Significance of the cystic node in preventing major bile ductinjuries during laparoscopic cholecystectomy: a technical marker. J LaparoendoscAdv SurgTech A. 2003 Oct;13(5):321–3.
18.PeitzmanAB, Watson GA, Marsh JW. Acute cholecystitis: When to operate and how to do itsafely. J Trauma Acute Care Surg. 2015 Jan;78(1):1–12.
19.RajkomarK, Bowman M, Rodgers M, KoeaJB. Quadrate lobe: a reliable landmark for bile duct anatomy duringlaparoscopic cholecystectomy. ANZ J Surg. 2016 Jul;86(7–8):560–2.
20.Rosenberg J, LeinskoldT. Dome down laparosoniccholecystectomy. ScandJ Surg. 2004;93(1):48–51.
21.Scott-Conner CE, Hall TJ. Variant arterial anatomy in laparoscopiccholecystectomy. Am J Surg. 1992 Jun;163(6):590–2.
22.Singh K, OhriA. Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy. SurgEndosc.2006 Nov;20(11):1754–8.
23.Strasberg SM, EagonCJ, DrebinJA. The “hidden cystic duct” syndrome and the infundibular technique oflaparoscopic cholecystectomy–the danger of the false infundibulum. J Am CollSurg. 2000 Dec;191(6):661–7.
24.Strasberg SM. Error traps and vasculo-biliary injury in laparoscopic and opencholecystectomy. J Hepatobiliary PancreatSurg. 2008;15(3):284–92.
25.Strasberg SM, Brunt LM. Rationale and use of the critical view of safety inlaparoscopic cholecystectomy. J Am Coll Surg. 2010 Jul;211(1):132–8.
26.Strasberg SM, GoumaDJ. “Extreme” vasculobiliaryinjuries: association with fundus-down cholecystectomy in severely inflamedgallbladders. HPB (Oxford). 2012 Jan;14(1):1–8.
27.Strasberg SM, Helton WS. An analytical review of vasculobiliaryinjury in laparoscopic and open cholecystectomy. HPB (Oxford). 2011Jan;13(1):1–14.
28.Strasberg SM, Pucci MJ, Brunt LM, DezielDJ. Subtotal Cholecystectomy-“Fenestrating”vs “Reconstituting” Subtypes and the Prevention of Bile Duct Injury: Definitionof the Optimal Procedure in Difficult Operative Conditions. J Am CollSurg. 2016 Jan;222(1):89–96.
29.Strasberg SM. A three-step conceptual roadmap for avoiding bile duct injury inlaparoscopic cholecystectomy: an invited perspective review. J Hepatobiliary PancreatSci. 2019 Apr;26(4):123–7.