CULTURE OF SAFETY IN LAPAROSCOPIC CHOLECYSTECTOMY (COSIC) SAFE LAPAROSCOPIC CHOLECYSTECTOMY

1. SAFE LAPAROSCOPIC
CHOLECYSTECTOMY
PRESENTER: DR ANAND UJJWAL SINGH
MODERATORS:
DR SURESH SAH
DR KUNAL BIKRAM DEO

2. LEARNING OBJECTIVES:
• History and Background
• Anatomy and Variations
• Important steps
• SAGES 6 Strategies
• Predictors of difficult cholecystectomy
• Error traps
• Stopping rules
• Bail out strategies
• Subtotal cholecystectomy
• Emerging role of ICG for difficult cholecystectomy
• Our institutional experience
• Conclusion

3. HISTORY AND BACKGROUND
• Most common surgical procedures performed
• Open cholecystectomy- Carl Langenbuch (1882)
• First Laparoscopic cholecystectomy (LC)  Erich Mühe
of Boblingen, Germany (1985)

4. ANATOMY AND VARIATIONS:
Bailey & Love’s 27th Ed

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6. Bailey & Love’s 27th Ed

7. Strasberg et al, An analytical review of
vasculobiliary injury in laparoscopic and open
cholecystectomy, HPB 2010

8. Strasberg et al, An analytical review of
vasculobiliary injury in laparoscopic and open
cholecystectomy, HPB 2010

9. Strasberg et al, An analytical review of vasculobiliary
injury in laparoscopic and open cholecystectomy, HPB
2010

10. IMPORTANT STEPS:
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12. SAGES 6 STRATEGIES:
1. Critical View of Safety (CVS)
2. Intra-operative time-out prior to clipping, cutting or transecting any ductal
structures is advised.
3. Variations in anatomy should be considered in all cases.
4. Surgeon should use cholangiography or other instrument for demonstrating
biliary anatomy.
5. In case of difficulty to expose biliary anatomy alternatives surgical techniques
such as partial cholecystectomy, cholecystostomy tube placement or conversion to
an open
Procedure.
6. Consultation with an another surgeon in difficult cases may be helpful.
SAGES (Society of American Gastrointestinal
and Endoscopic Surgeons), 2008.

13. Strasberg in 1995- “Critical View of Safety” (CVS)
1. Meticulous dissection of the Calot’s triangle from all fatty and fibrous
tissue.
2. Lowest part of gallbladder should be separated from the cystic plate,
which allows the visualization of posterior liver bed.
3. Dissection and identification of only two structures (cystic duct, cystic
artery) entering the gallbladder.
Strasberg SM et al, J Am Coll Surg 2008

14. Blumgart’s Surgery of liver,
Biliary tract and Pancreas
6th Ed

15. Proper gallbladder retraction for exposure of triangle of
Calot (A) and reverse triangle of Calot (B)

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19. CVS ANTERIOR
THE SAGES SAFE
CHOLECYSTECTOMY
PROGRAM

20. CVS POSTERIOR
THE SAGES SAFE
CHOLECYSTECTOMY
PROGRAM

21. Rouviere’s sulcus:
• 2-5 cm long
• Present on the under surface of right lobe of liver, running to the right of the
hepatic hilum
• Easily visible in 80% of cases
• Remains open (partly or fully)
• Usually contains right portal pedicle or its branches
• Best seen during LC when GB neck is retrated towards the umbilical fissure.

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23. R4U LINE: All the dissection during LC must be done ventral and
cephalad to the line joining Rouviere’s Sulcus and base of segment 4.
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24. CONCEPT OF “TIMEOUT”:
Use B-SAFE to be 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 artery.
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25. PREDICTORS OF DIFFICULT CHOLECYSTECTOMY:
HISTORY:
• Male gender
• Higher age ( >65 yr)
• Increased interval between onset and presentation ( > 72-96hrs) in acute cholecystitis
• Previous multiple attacks of biliary colic
• History of acute cholecystitis
• Upper abdominal surgery
• Prior attempt at cholecystectomy ( including cholecystotomy)
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26. PHYSICAL EXAMINATION:
• Fever
• Higher ASA score
• Morbid obesity
LABORATORY TESTS:
• Raised leucocyte count ( > 18000/mm3)
• Raised C- reactive protein
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27. IMAGING ( USG/CT/MRI-MRCP):
• Thick walled GB ( > 4-5mm)
• Small contracted GB
• Distended GB with impacted stone in neck
• Gangrenous GB/ GB perforation
• Mirizzi syndrome/ Cholecystoenteric fistula
• Cirrhosis/ EHPVO (portal cavernoma) with Portal HTN
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28. INTRAOPERATIVE:
• Small shrunken GB not visualized on initial exploration
• Liver edge retracted with fissure/ depression/ puckering near fundus
(Liver pucker sign)
• Fatty/ Firm Cirrhotic liver (difficulty in retraction)
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29. ERROR TRAPS:
• Infundibular technique error trap
• Fundus down error trap
• Failure to perceive the presence of an aberrant right hepatic duct on
cholangiography
• “Parallel union” cystic duct
STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)

30. Infundibular technique error trap:
STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)

31. STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)
Fig:
CHD is tightly applied to GB
obliterating the triangle of Calot
resulting CBD injury.

32. Fundus down error trap:
STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)

33. STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)

34. STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)
Fig:
Course of dissection leading to
vasculobiliary injury (as shown by arrow)

35. STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)
Figure: Postoperative CT scan
Portal vein (arrowhead)
disconnected from its branches
(arrow).
Right liver is underperfused,
(infarction following surgery)

36. Aberrant Right hepatic duct (IOC):
STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)
Fig:
Intraoperative cholangiogram showing normal
biliary anatomy but with poor filling of right
hepatic ducts
Stone at lower end of bile duct (arrow)

37. STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)
Fig: ERCP done to remove the stone.
Injury with narrowing of right hepatic duct seen
adjacent to clips.
Impression: Aberrant Low Lying right hepatic
duct

38. Parallel union cystic duct:
STEVEN M. STRASBERG et al , J Hepatobiliary Pancreat Surg (2008)

39. THE CLASSICAL INJURY:
Strasberg et al, An analytical review of vasculobiliary
injury in laparoscopic and open cholecystectomy,
HPB 2010

40. Strasberg et al, An analytical review of vasculobiliary
injury in laparoscopic and open cholecystectomy,
HPB 2010

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42. STOPPING RULES: IDENTIFICATION OF RED FLAGS
• More than 2 tubular structures entering GB
• Unusually large presumed cystic artery ( this may be hepatic artery)
• Large artery pulsations present behind the presumed cystic duct ( this
duct maybe common hepatic/ bile duct)
• Medium-large clip fails to occlude ductal lumen ( this duct maybe
hepatic/ bile duct)
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43. • Large ductal structures that can be traced behind the duodenum
( this duct is common bile duct)
• Excessive fibrofatty/ lymphatic tissue noted around the presumed
cystic duct ( this maybe common hepatic/ bile duct)
• Bile leak seen with intact GB
• Bleeding requiring blood transfusion.
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44. BAILOUT STRATEGIES:
1. PARTIAL CHOLECYSTECTOMY
2. SUBTOTAL CHOLECYSTECTOMY

45. • Partial vs Subtotal cholecystectomy
SUBTOTAL CHOLECYSTECTOMY – “FENESTRATING” VS “RECONSTITUTING”
SUBTYPES AND THE PREVENTION OF BILE DUCT INJURY, STRASBERG M ET AL, J AM
COLL SURG 2015

48. • Which technique is best may vary with experience of surgeon.
• Trained surgeon in Minimally invasive technique  Subtotal
fenestrating cholecystectomy
• Safest approach  Open procedure of same type
• Subtotal Fenestrating Cholecystectomy is a standard operation that
should be used liberally when surgeons encounter difficulty in getting
to the CVS.
SUBTOTAL CHOLECYSTECTOMY – “FENESTRATING” VS “RECONSTITUTING”
SUBTYPES AND THE PREVENTION OF BILE DUCT INJURY, STRASBERG M ET AL, J AM
COLL SURG 2015

49. Blumgart’s Surgery of liver,
Biliary tract and Pancreas
6th Ed

50. ROLE OF ICG:
• Intraoperative cholangiography involving the excretion of fluorescent
indocyanine green (ICG) into the bile is used to determine biliary anatomy
in laparoscopic cholecystectomy (LC).
• NIRF-C (Near Infrared Fluorescence Cholangiography) appears to be a
safe, effective, and efficient method for identifying extrahepatic biliary
anatomy during laparoscopic cholecystectomy.
Mark R Wendling, MD ET AL, SAGES ANNUAL UPDATE
ARCHIVE, The Ohio State University Wexner Medical
Center

51. • Non-invasive method of real-time
• Radiation free
• Intra-operative biliary mapping
• Pre-operatively, a fluorescent dye, indocyanine green (ICG), is administered
intravenously. Bound to plasma proteins, ICG is taken up by hepatocytes and
excreted, unaltered, in bile within 20 minutes.
• A laser on the laparoscope excites ICG in the biliary tree eliciting near infrared
fluorescence (~800 nm) which is captured by an image filter on the laparoscope.
• Surgeons may toggle between NIRF-C and the standard view on the laparoscope.
Mark R Wendling, MD ET AL, SAGES ANNUAL UPDATE
ARCHIVE, The Ohio State University Wexner Medical
Center

52. Bile Duct injuries during Open and Laparoscopic Cholecystecomy : Management
and Outcome
Gupta RK, Agrawal CS, Sah S, Sapkota S, Pathania OP, Sah PL
Journal of Nepal Health Research Council, May 2013
• Retrospective Observational study January 2001 to September 2010
• Total patients with BDI: 92
• 60/92 (65.5%) wrong identification of the anatomy of the Calot's
triangle during cholecystectomy
• Strasberg's E2 in 65/92 (70.7%)
• Repaired  Hepaticojejunostomy (83 cases)
• 75 (81.5%) patients were followed up (Mean follow-up time  2.6
years
• Good results were achieved in 62/75 (82.6%) of the patients

53. COSIC ( CULTURE OF SAFETY IN
CHOLEYSTECTOMY)
The key components of the COSIC, summarized as ABCD of safe LC
include:
1. A clear understanding of relevant anatomy
2. Appropriate and timely use of bailout technique
3. Obtaining CVS prior to division of cystic duct and artery in every
case
4. Recognizing the importance of time-out
5. Use of intraoperative imaging
6. Obtaining a second opinion in difficult cases
7. Importance of proper documentation
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54. CONCLUSION
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55. What could be the possible injury?