The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

1. ABCD of Safe Lap Chole
PROF. DR SREEJOY PATNAIK
E.C MEMBER ASI ,
EX- ORGANISING SECY - ASICON & IAGES 2019, BHUBANESWAR
SHANTI MEMORIAL SUPER SPECIALITY HOSPITAL
CUTTACK
ODISHA

2. Culture of safety in cholecystectomy, adopted by
“SAGES SAFE CHOLECYSTECTOMY PROGRAM”
Minimize Bile Duct Injuries
Educate surgeons and apprise them of basic tenets of safe performance of LC
COSIC

3. INTRODUCTION
Most commonly performed procedure worldwide.
It is one of the more unpredictable operations in general Sx, due to variable operative findings.
A safe cholecystectomy is one that is safe for both the patient and for the surgeon. ( Medico-legal)
The incidence of biliary injury declining 2T in OC.
Major BVI - significant morbidity.
Recent data -BDI rates (0.32%-0.52%) without any significant change in the morbidity or mortality.
Prevention is the best strategy.

4. The Pearls of wisdom for a safe Laparoscopic cholecystectomy:
1.Knowledge of surgical relevant anatomy
2.Factors predictive of difficult cholecystectomy.
3. Execution of Correct technique
4.Concept of “Time-Out”.
5.Judicious use of Energy devices.
6.Understanding CVS.
7.Remembrance of Error Traps
8.Understanding “stopping rules”
9.Use of Intraop. Imaging techniques
10.Bailout strategies
11. Documentation

5. 1.Knowledge of Surgical relevant anatomy:
Vital structures (portal vein, hepatic artery and extrahepatic biliary tract).
Common anatomical variations, and distortions due to pathological processes (e.g.,
acute/chronic cholecystitis).
Safe execution -understanding of following anatomical terms/landmarks.

6. The Anatomical terms / Landmarks.
Hepatocystic triangle
Cystic plate
Rouviere’s sulcus
Umbilical fissure
Segment 4 liver
Anatomical Vascular variations
Biliary ductal anomalies

7. Hepatocystic triangle
This is an area on the under surface of the
liver on the right side of the hepatic hilum.
Boundaries:
1.CHD on the medial side
2.Cystic duct caudally.
3.Liver under surface cranially.
Contents:
Cystic artery
Variable portion of RHA
Cystic lymph node
Lymphatics
Fibro-fatty connective tissue.
Anatomy of hepatocystic and Calot’s triangles.
A: Hepatocystic triangle (red outline); Calot’s triangle (in blue); Relevant anatomical structures;
B: Before dissection;
C: After dissection. CD: Cystic duct; CA: Cystic artery; LN: Lymph node; HAP: Hepatic artery proper; CBD: Common bile duct.

8. Clinical significance:
This is the target area for dissection during LC.
The cystic lymph node often lies superficial to the CA - landmark to locate this
artery.
The CA should be divided on the right side of this lymph node close to the
gallbladder to avoid injury to the right hepatic artery.
Difficult cases – inflammation + - thick, fibrotic, or scarred - difficulty in anatomical
identification and/or dissection.

9. Cystic plate
This is a flat ovoid fibrous sheet located in the gallbladder bed / a part of the liver.
With GB in-situ, not visible as it is covered by it.
It is continuous with liver capsule of segment and segment 5.
Postero-medially at hepatic hilum, it narrows to become a stout cord like structure that
is continuous with the sheath of the right portal pedicle
It is exposed as whitish/greyish structure once the gallbladder is dissected off the liver.
Cystic plate is visualized after the gallbladder is dissected
off its liver bed.

10. Clinical significance:
The lower 3rd cystic plate needs to be exposed to achieve the CVS.
Dissection should remain close to the GB wall while dissecting it off the liver bed.
Incomplete exposure – injury to an anomalous duct (e.g., right posterior sectional
duct).
Inflammation – longitudinal length of CP leads to pathological shortening.
Any Breach –
1.Troublesome bleeding from liver parenchyma, especially if the terminal tributaries
of the middle hepatic vein.
2.Sub-vesical bile ducts (close to GB fossa) may be injured, causing a postoperative
bile leak.
Understanding surgical planes during dissection.
A: Usually, in uncomplicated cases, plane of dissection remains close to the gallbladder that
leaves behind the cystic plate attached to liver;
B: In chronic cholecystitis, with small shrunken gallbladder, liver puckering develops (red curved
arrow) with shortening of the cystic plate (black interrupted arrow). With loss of plane, the
surgeon tends to breach the cystic plate (red arrows) resulting in bleeding from the liver. In
addition, there is a risk to enter in to the right portal pedicle during fundus first approach (blue
arrow) if such danger is not appreciated;
C: Pucker sign as noted during open cholecystectomy;
D: Small contracted scarred gallbladder (in white circle) was identified after separating adherent
omentum and colon. Duodenum (Du) was densely adherent to the gallbladder. Findings such as
in C and D suggest difficult cholecystectomy.

11. Rouviere’s sulcus :
This sulcus is 2-5 cm long and is present on the under surface of the right lobe of the liver, running to the right
of the hepatic hilum .
Visible in (80%) cases, remains open (partly or fully) - contains right portal pedicle or its branches.
Best visible -GB neck is retracted towards the umbilical fissure .

12. Clinical significance
Fixed anatomical landmark .
It indicates the plane of the CBD thus helps to reorient surgeon in cases of difficultly.
All the dissection must be done cephalad to the (R4U line) .
The fissure of Gans is also known as Rouvières sulcus or the incisura hepatis dextra.

13. B-SAFE anatomical landmarks and R4U safety line.
If Rouviere’s sulcus is not present.
B-SAFE and R4U safety line - Safe zones of dissection:
B-SAFE:
(B) Bile duct and base of segment 4
(S) Rouviere sulcus and segment 4
(A) Hepatic artery
(F)Umbilical fissure
(E)Enteric viscera e.g., duodenum, pylorus.
R4U safety line: ( LAKSHMAN REKHA)
Is an imaginary line passing across the base of the segment 4 from the umbilical
fissure extending right across the hepatoduodenal ligament. It ascertains safe
zone of dissection.
R- Rouviere sulcus
4- segment 4
U- Umbilical fissure

14. Sulcus acts as a fixed anatomical landmark during LC.
Indicates the plane of the CBD thus helps to reorient surgeon in cases
of difficultly.
All the dissection must be done ventral and cephalad ( SAFE) to the line
joining the roof of this sulcus and base of segment 4 (R4U line)
No dissection to be done below this line / landmark.(UNSAFE)
Clinical Significance

15. Umbilical fissure:
This is a fissure between the left lateral section (segments 2, 3) and
left medial section (segment 4) where the falciform ligament and
ligamentum teres lie.
Clinical significance: This also acts as a fixed anatomical landmark,
and helps the operating surgeon to reorient in difficult situations.

16. Segment 4
This is the left medial section of the liver.
Location - between the umbilical fissure and the
gallbladder
Segment 4 lies lateral to the falciform ligament and
is subdivided into 4a (superior) and 4b (inferior)
Segment 4 a & b

17. Anatomical variations : Vascular anomalies
The cystic artery ( CA) and the right hepatic artery (RHA) 2
important vessels.
The cystic artery is usually single (approx. 79%), originates from
RHA.
In 81.5% traverses the HCT to supply GB by 2 branches – Superf. &
deep.
Variations in its origin, number, or course.
Pass anterior to the common hepatic/ bile duct (17.9%)
Short (< 1 cm) cystic artery (9.5%)
Multiple cystic arteries (8.9%)
Located inferior to the cystic duct (4.9%)

18. Significance:
Short Cystic Artery - RHA may be clipped and divided.
Dissection close to the GB & Rt. side of the cystic lymph node.
Cystic Artery may not be localised or -Low lying -- arising from GDA or LHA
(doesn’t pass through HCT.)
RHA:- pass behind the CHD (87%).
Aberrant RHA(replaced or accessory):
Courses behind the portal vein and CBD, comes to lie on the rt. side of the bile duct.

19. Clinical importance:
Replaced RHA - large cystic artery - might be
injured if not identified correctly.
RHA may take a tortuous course (Caterpillar
turn/Moynihan’s hump) a short CA.
Caterpillar turn/Moynihan’s hump)

20. Biliary ductal anomalies : Cystic ductal variations, anatomical and pathological
The CD - 2-4 cm long and 2-3 mm wide.
Congenitally absent (very rare) / very long ( >5
cm ).
 Angular insertion- 75%
 Parallel -20%
 Spiral - 5%
 Enter the RHD - 0.6%-2.3% ( anomalous right
sectional duct)
 Enter CHD quite low near the ampulla.
An anomalous right sectional duct, especially a
right posterior sectional duct, may join the
biliary tree at a level lower than usual
Duplication of the CBD.
E: Short/effaced cystic
duct due to impacted
stone in the gallbladder
neck
A: Normal
pattern with
angular
insertion
B: Cystic duct
insertion in
aberrant right
hepatic
(sectional) 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
In D and E, CHD would be at risk of injury – on exposing the
CD –CBD junction.

21. Clinical importance:
 CYSTIC DUCT AND COMMON HEPATIC DUCT VARIATIONS:
 The length ,course & it’s joining pattern of the Cystic duct with CHD are variable.
Inflammation - may be adherent and fused with parallel insertion .
 Shortened or effaced by the impacted stone (Mirizzi”s Syndrome).
 The surgeon should be careful - may need to resort to one of the bail-out techniques.

22. 2. Factors Predictive of Difficult Cholecystectomy

23. Gallbladder is not visualized in both of these
situations predicting difficult dissection.
The surgeon should be careful during dissection as
adjoining adherent viscera, duodenum or colon,
might be injured during adhesiolysis.
AModerate pericholecystic adhesions
Extensive pericholecystic adhesion.
Examples of intraoperative prediction of difficult gallbladder.

24. A comprehensive scoring system, e.g., CLOC score, may also be useful
in clinical practice to predict conversion to open cholecystectomy.
Low risk patients (CLOC score <6) are suitable for surgical
registrars in the early phase of training.
High risk patients (CLOC score > 6) should be operated by
experienced surgeons.
CLOC SCORING – LAP – OPEN

25. Nassar difficulty grading score

26. 3.EXECUTION OF CORRECT TECHNIQUE:
The basic essential steps of LC include:
1. GB retraction (to open up and expose HC triangle in preparation for next step),
2. Dissection in the HC triangle to achieve the CVS.
3. Clipping and division of the cystic duct and the cystic artery.
4. Dissection of the GB from its bed
Correct exposure/display of the HC triangle:
FUNDAL AND INFUNDIBULAR RETRACTIONS - VERY IMPORTANT IN ACHIEVING CVS .
Proper retraction opens up the HC triangle - Diamond shape ( Extended Biliary triangle) that
gradually becomes more appreciable as the dissection proceeds till CVS is achieved .

27. Importance of proper retraction of gallbladder during laparoscopic cholecystectomy.

28. Proper retraction of infundibulum:
A: Exposure of anterior aspect of hepatocystic (HC)
triangle when infundibulum is retracted in right
inferolateral direction
B: Exposure of posterior aspect of HC triangle
when infundibulum is retracted towards umbilical
fissure.
If the infundibulum is not retracted adequately in the
correct direction, the CBD will be pulled towards the
RUQ ,resulting in parallel alignment of the CD and the
CBD
In this situation the CBD may be mistaken for the CD.

29. Difficult scenarios: Useful manoeuvres
A. Difficulty in grasping and retracting the fundus, the GB may be decompressed by aspiration, or a stay suture may
be taken to facilitate retraction
B. Impacted large stone in the Hartmann’s pouch -- dislodge before the GB can be grasped and retracted
properly
C. A firm liver, as in cirrhosis, - Retraction can be facilitated by taking stay sutures.

30. Safe zones of dissection
Surgeon to know the safe zone of dissection to delineate the cystic duct and the cystic artery.
Fixed anatomical landmark (B-SAFE) will help the surgeon to identify and remain in the safe zone of
dissection.
Surgical field of interest during laparoscopic cholecystectomy. It is important to
identify safe (green) and danger (red) zones of dissection as demarcated by R4U
line.
B-SAFE anatomical landmarks and R4U safety line

31. 4.Concept of “time-out”

32. Flowchart showing overall scheme of performance of laparoscopic cholecystectomy with the culture of safety concept.
GB: Gallbladder; B-SAFE: Surgical landmarks; HC triangle: Hepatocystic triangle; CVS: Critical view of safety.
TIME OUT 1
TIME OUT 2
TIME OUT 3

33. 5.Judicious use of energy sources
Energy devices used to dissect the HCT and to separate the GB from its bed:
1. Monopolar cautery
2. Bipolar cautery
3. Ultrasonic energy devices.
All these energy sources are appropriate for safe LC.
Awareness of safe handling of these energy devices.
Monopolar hook important points:
1. Keep it at low setting (≤ 30W) to avoid arcing of current to the bile duct.
2. Divide a small amount of tissue at a time after a gentle pull to avoid injury to deeper structures by the heel of the hook cautery;
3. Use intermittent short bursts of current at 2-3 s intervals avoid thermal spread to the bile duct.
4. Avoid blind use of cautery in the case of brisk bleeding.
Ultrasonic energy source. – best as considering its minimal lateral spread.
Bipolar cautery is useful to control bleeding in the HC triangle and in the liver bed.

34. 6. Concept of the CVS
The concept of the “CVS” was introduced in an attempt to decrease the misidentification injury of
structures in the HCT.
Its aim - conclusive identification of the cystic duct and the cystic artery (two targets) to avoid
misidentification injury.
The HCT dissection is done to achieve the Extended hepatobiliary triangle-
- lower boundary which is formed by the part of the GB along with the CD.
- upper boundary is also formed by the cystic plate along with the liver surface.
This enhances the safety margin against misidentification of any aberrant structures, and also saves
time during subsequent dissection after the cystic duct and the artery have been divided.

35. What is the CVS?
DEFINITION:
It is the final view that is achieved after a thorough dissection of the HCT to delineate the cystic duct and the cystic artery before
they are clipped and divided.
The CVS has 3 components and all must be met for achieving it.
1.Clearance of the HC triangle: The HC triangle should be cleared of all the fibro- fatty and soft areolar tissue. The under surface
of the liver is easily seen across this triangle.
2. Exposure of the lower cystic plate: The GB should be separated from its liver bed to expose at least the lower 3rd of the cystic
plate.
3. Two and only two tubular structures should be seen entering the gallbladder: the Cystic duct and the cystic artery.

36. Doublet view: CVS
Anterior view Posterior view (inverted hepatocystic triangle).
The CVS should be seen clearly both from front and the back to have complete circumferential visualization of cystic duct and artery (doublet view).
The anterior view is easily visible by retracting the infundibulum infero-laterally towards right (with segment 5 surface visible across window) while the posterior view
(inverted/reverse HC triangle) requires the infundibulum to be retracted towards the umbilical fissure (with segment 4/quadrate lobe surface visible across window)
Complete circumferential visualization of cystic duct and artery (doublet view)

37. Clinical importance of the CVS
 Most effective method/ technique of preventing BDI as reported in many recent studies.
 Surgeons must incorporate it in routine practice.
 Understand the concept and use it correctly.
 Barrier - biliary- vascular injury.
 Method of target identification.
 Failure to achieve- higher risk of injury – continue dissection.

38. Important steps during laparoscopic cholecystectomy.

39. Lap Chole – steps

40. 7.Remembering error traps
Apart from CVS, there are other techniques of target identification during LC
1.Infundibular techniques.
2.Fundus first technique.
3.Intraoperative cholangiogram.
Surgeons using this technique should always be aware of this error trap.
Fallacies :
The deception of the hidden cystic duct and the CHD junction .
Left: Appearance to surgeon when a duct
appearing to be the cystic duct is dissected
first.
Right: True anatomic situation in the case of some
classical injuries.
The “flare” (heavy black line) is from the separation of CD
and CHD or its side & the side of the gallbladder.
In the infundibular technique, cystic duct identification is
based on the appearance of the infundibulum-cystic duct
junction as a funnel.
CBD may be misidentified as the cystic duct –
This leads to classical BDI where the CBD is divided twice before the gallbladder could be completely separated from the liver.

41. In the) the GB fundus is dissected first off its liver bed/cystic plate, lastly the CD
and the artery are divided.
Another error trap for the surgeon - local anatomy of the cystic plate not well
appreciated.
GB tends to twist once separately completely from the liver - technical challenge of
handling.
Difficult Retraction of liver. - small shrunken fused GB.
Pathological shortening of the CP ( Puckering) - Breach in CP -right portal pedicle
or hilar injuries.
With loss of plane, breaching the cystic plate (red
arrows)
Fundus first technique ( dome-down technique)

42. 8.Understand “Stopping rules.”
The surgeon should recognize these clues, stop the dissection, and then to decide the strategy for a safe operation before the
dissection starts again (use “time-out”).

43. Call for help/second opinion / Assistance
It is advisable that operating surgeon should take a pause and seek a 2nd opinion from another surgeon in event of
any-
 unexpected finding
 difficult GB,
 unusual anatomy
 difficult dissection.
 Misidentification is the major cause of biliary/vascular injury:
 CBD/CHD is misidentified as the cystic duct – (65%)
 Hepatic artery is misidentified as the cystic artery (10%).
 Can be prevented with the advice from a 2nd surgeon -18% .
It should be considered as a sign of good clinical practice rather than a sign of surgical ineptitude.

44. Techniques of intraop. assessment of biliary anatomy that may result in decreased incidence of BDI..
Intraoperative cholangiography (IOC):
 It is the most commonly performed.
 Identification and assessment of extent of biliary injury, and possible prevention of BDI .
 It is a safe technique
 90%–95% success rate.
 Detects asymptomatic CBD stones.
 Pitfalls:
 Ductal cannulation can be difficult in patients with short and thin cystic ducts.
 Adds to the operative time and cost
 High learning curve involved for correct interpretation.
 There is need for radiographic equipment.
9.Use of intraoperative imaging

45. Laparoscopic ultrasound: LUS
Many outcome studies support LUS for prevention of BDI.
 Non-invasive.
 Shorter procedure time
 Higher success rates
 Lack of radiation exposure.
Pitfalls:
 Less accurate for the assessment of the intrapancreatic and intrahepatic parts of the biliary system.
 Long learning curve.
Near infrared fluorescent ICG cholangiography:
NIRFC is the most recent addition to the armamentarium for intraop. assessment of biliary tract.
 Its efficacy and safety have been confirmed in various studies.
 takes less time
 cheaper and safer.
 new technique, its use in various biliary pathologies has not yet been evaluated.

46. ICG LAP CHOLECYSTECTOMY VIDEO

47. 10.Bailout strategies
Bail out techniques - alternate procedures that allows the surgeon to complete the procedure in a safe manner. (i.e., safety first). in a difficult
situation.
The goal is not not to go ahead and complete the procedure - & risking patient safety due to potential of BVI injury.
Follow the 5 bailout strategies in difficult situations :
1. Abort the procedure altogether
2. Convert to an open procedure
3. Tube cholecystostomy
4. Subtotal cholecystectomy (STC, open/lap)
5. Fundus first cholecystectomy
The best choice will depend on the clinical judgement and the experience/expertise of the surgeon.

48. Laparoscopic subtotal cholecystectomy - bailout procedure.
A: Mucosa of the gallbladder stump is fulgurated after removal of
as much gallbladder as safely possible
B: Stump is closed after ensuring no stone is left behind in this stump.
2 types of STC - kept closed or is left open.
This stump may vary in length and part of the GB wall may be left attached to the liver in both types.
 STC - the stump is closed, either with sutures or with staples.
 Subtotal fenestrating cholecystectomy - the stump is left open, with or without closing the cystic duct opening.

49. Empyma GB , impacted stone

50. 11.DOCUMENTATION
 Since malpractice claim in GI Surgery is most common – one should strictly adhere to meticulous documentation.
 As Literature is scant, OT notes reflect what was actually performed during the operation.
 Vigilant - writing OT notes.
 Inadequate documentation - “error-trap” as 20%-30% of lap. biliary injury - malpractice litigation.
 All descriptions of the measures taken (e.g., achieving CVS) + photo/video should be documented.
 STC performed – mention type and the size of gallbladder stump - for future reference - recurrent stones in the
stump.

51. Advise to every surgeon & team involved in LC should be aware of the concept of “COSIC”.
Should be routinely adopted & practiced in each & every case.
Always remember the 11 points which I mentioned
CONCLUSION :