The rationale of critical view of safety in laparoscopic cholecystectomyA study done in Al Diwanyia teaching hospital

2018 ◽  
Vol 9 (SPL1) ◽  
Author(s):  
Muayad Alkhafaji ◽  
Ahmed Alsagban ◽  
Rawya Reyadh Abbood
Keyword(s):  
Bile Duct ◽  
Acute Cholecystitis ◽  
Teaching Hospital ◽  
Cystic Duct ◽  
Operating Time ◽  
Chronic Cholecystitis ◽  
Critical View ◽  
Safe Method ◽  
Critical View Of Safety ◽  
Calot’S Triangle

Laparoscopic cholecystectomy (LC) has become the standard method for the removal of a diseased gallbladder. The technique most commonly employed is the infundibular approach which entails dissecting the gallbladder (GB) from its neck upward, after dissecting the cystic artery and cystic duct using laser or electrocautery. Common bile duct (CBD) injury is one of the most serious complications of LC. misidentification of the bile duct during dissection of the Calot's triangle can lead to such injuries. The critical view of safety (CVS) has been recently discussed in controlled study, it is characterized by dissection of the upper part of the Calot's space, which does not usually contain arterial or biliary anomalies so it is ideal for a safe dissection even in less experienced hands2. This study was amid to introduce a safe method for dissection of the GB away from CBD which forms one boarder in the Calot's triangle. This Prospective clinical analysis of 1000 cases of LC was utilizing the CVS technique over a period from January 2014 to January 2017 was conducted at Al-Diwanyia Teaching Hospital Laparscopic Center.The diagnosis of acute cholecystitis, chronic cholecystitis and cholilithiasis was established with history, physical examination, and ultrasound examination. The patients were categorized for sex, age, operating time and post operative There were 270 (27%) LC for (acute cholecystitis) and 730 (73%) LC for (chronic cholecystitis and cholilithiasis). There were minor significant complications when compared with CBD injuries complications, with short operating time (mean time for operation in our study35.9 minutes). Critical view of safety (CVS) seems to be a safe method of dissection that clearly demonstrating the cystic duct and help to reduce the bile duct injuries.  

scholarly journals Optimal surgical technique, use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland

2010 ◽  
Vol 92 (4) ◽  
pp. 302-306 ◽  
Author(s):  
P Sanjay ◽  
C Kulli ◽  
FM Polignano ◽  
IS Tait
Keyword(s):  
Bile Duct ◽  
Bile Duct Injury ◽  
Teaching Hospital ◽  
Gallbladder Disease ◽  
Critical View ◽  
Operative Cholangiography ◽  
Critical View Of Safety ◽  
Calot’S Triangle ◽  
Laparoscopic Cbd Exploration ◽  
Cbd Exploration

INTRODUCTION There is debate on optimal techniques that reduce bile duct injury during laparoscopic cholecystectomy (LC). A national survey of Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) members was carried out to determine current surgical practice for gallstones, including the use of intra-operative cholangiography (IOC) or critical view of safety to reduce the risk of bile duct injury. SUBJECTS AND METHODS An anonymous postal survey was sent to all 417 AUGIS members. Data on grade of surgeon, place of work (district general hospital, teaching), subspecialty, number LC per year, use of IOC, critical view of safety, and management of stones detected during surgery were collated. RESULTS There was a 36% (152/417) response – 134 (88%) from consultant surgeons (36, HPB; 106,OG; 64, DGH; 88, teaching hospital). Of these, 38% performed > 100 LC per year, 36% 50–100 LC per year, and 22% 25–50 LC per year. IOC was routine for 24%; and selective for 72%. Critical view of Calot's triangle was advocated by 82%. Overall, 55% first clip and divide the cystic artery, whereas 41% first clip and divide the cystic duct. Some 39% recommend IOC and 23% pre-oper-ative MRCP if dilated common bile duct (CBD) is noted on pre-operative ultrasound. When bile duct stones are identified on IOC, 61% perform laparoscopic CBD exploration (LCBDE), 25% advise postoperative ERCP, and 13% perform either LCBDE or ERCP. Overall, 88% (n = 134) recommend index cholecystectomy for acute pathology, and this is more likely in a teaching hospital setting (P= 0.003). Laparoscopic CBD exploration was more likely to be performed in university hospitals (P< 0.05). CONCLUSIONS A wide dissection of Calot's triangle to provide a critical view of safety is the technique most commonly recommended by AUGIS surgeons (83%) to minimise risk of bile duct injury, in contrast to 24% that recommend routine IOC. The majority (88%) of AUGIS surgeons advise index admission cholecystectomy for acute gallbladder disease.

scholarly journals Intraoperative strategies to overcome difficulties in laparoscopic cholecystectomy for chronic calculous cholecystitis

2021 ◽  
Vol 8 (4) ◽  
pp. 1160
Author(s):  
Mohinder Singh ◽  
Dipesh Goel
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Gall Bladder ◽  
Chronic Cholecystitis ◽  
Critical View ◽  
Critical View Of Safety ◽  
Calot’S Triangle ◽  
Group A ◽  
Group B ◽  
A Prospective Study ◽  
Calculous Cholecystitis

Background: Surgery in chronic cholecystitis is very challenging because of inability to hold the gall bladder, dense adhesions, frozen Calot’s triangle and difficulty in applying clips. Precise and meticulous dissection is required to establish critical view of safety. There is no consensus among surgeons about appropriate intraoperative steps in difficult gall bladder (GB) surgery. The authors aim to present various intraoperative difficulties and strategies to overcome them.  Methods: A prospective study of 81 patients of chronic cholecystitis was done in our institution. They were divided in two groups. Group A in which surgery could be done easily. Group B in which surgery was difficult and different intraoperative strategies were applied to overcome them. Results: Total 42 patients were included in group A and 39 patients in group B. Various difficulties encountered while performing laparoscopic cholecystectomy in group B were adhesions (53.8 %), inability to grasp the fundus of GB (15.3%), frozen Calot’s triangle (15.3%), inability to grasp the Hartmann’s pouch (12.8%) and cystic duct edema (2.5%).  Conclusions: Intraoperative technique of identification of Rouviere′s sulcus first, followed by high peritoneal incision on the GB body. Subsequently blunt dissection of Calot’s triangle using gauze piece and hydro dissection by suction irrigation canula ventral to the sulcus. It created a retro gall bladder tunnel safely. It established the critical view of safety in all our cases. 

scholarly journals Colecistitis aguda en vesícula biliar izquierda. Presentación de un caso resuelto en forma segura por vía laparoscópica

2021 ◽  
Vol 113 (1) ◽  
pp. 125-130
Author(s):  
Agustín Virgili ◽  
◽  
Carlos Wendichansky ◽  
Rodrigo Maroni
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Laparoscopic Surgery ◽  
Bile Duct ◽  
Acute Cholecystitis ◽  
Preoperative Diagnosis ◽  
Direct Puncture ◽  
Critical View ◽  
Critical View Of Safety ◽  
Bile Duct Injuries ◽  
Bile Duct Anatomy

Left-sided gallbladder (LSGB) is a rare bile duct abnormality, usually found during a cholecystectomy. Symptoms usually do not differ from those of a normally positioned gallbladder, making the preoperative diagnosis extremely uncommon. We report the case of an acute cholecystitis in a patient whit LSGB, safely managed with laparoscopic surgery. A 24-year-old male patient was admitted to our institution with clinical and radiological signs of acute cholecystitis. The intraoperative finding of an acute cholecystitis in a LSGB made us modify ports positioning and a cholangiograhy was done by direct puncture of the gallbladder before hilum dissection. After the cystic duct was identified, a transcystic cholangiography was performed which confirmed a complete and clear bile duct anatomy and laparoscopic cholecystectomy was safely completed. The intraoperative finding of a LSGB makes the surgeon change some aspects of the usual technique to perform a safe cholecystectomy as LSGB significantly increases the risk of common bile duct injuries. Meticulous dissection of the gallbladder hilum to achieve a critical view of safety and the systematic use of intraoperative cholangiography are extremely important to perform a safe laparoscopic cholecystectomy.

scholarly journals Bile Duct Injury in Laparoscopic Cholecystectomy

2021 ◽  
Vol 15 (9) ◽  
pp. 2296-2297
Author(s):  
Mariam Fatima ◽  
Naeem Ghaffar ◽  
Muhammad Shahid Hussain
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Bile Duct ◽  
Bile Duct Injury ◽  
Gall Stone ◽  
Stone Disease ◽  
Critical View ◽  
Critical View Of Safety ◽  
Calot’S Triangle ◽  
Gall Stone Disease

Background: Laparoscopic cholecystectomy is commonly performed surgical procedure for symptomatic gall stone disease due to its better cosmetic results and shorter hospital stay; however, its safety in some cases is still questionable5. Methods: A retrospective, observational study was done in surgical unit 1, Sir Ganga Ram hospital, Lahore, from January 2017 to December 2019. Results: There were 209 cases whose surgical notes, hospital record and follow up notes were studied. Among these, 21 cases were converted to open. There was no injury of bile duct in any case. Conclusion: Experience of surgeon, careful dissection at calot’s triangle, use of critical view of safety and timely decision for conversion to open were factors participating insafe surgery. Keywords: Laparoscopic Cholecystectomy, Bile duct injury, critical view of safety

scholarly journals Rouviere\'s Sulcus and Critical View of Safety: A Guide to prevent Bile Duct Injury during Laparoscopic Cholecystectomy

2018 ◽  
Vol 11 (1) ◽  
pp. 25-28
Author(s):  
Tanweer Karim ◽  
Subhajeet Dey ◽  
Atul Jain ◽  
Malwinder Singh ◽  
Nabal Mishra ◽  
...  
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Bile Duct ◽  
Bile Duct Injury ◽  
Critical View ◽  
Critical View Of Safety

scholarly journals P-BN28 The Consistency of Operative Safety Markers and the Critical View of Safety During Laparoscopic Cholecystectomy: A Pilot Study

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Ahmad H M Nassar ◽  
Mahmoud Sallam ◽  
Rhona Kilpatrick ◽  
Kiren Ali
Keyword(s):  
Laparoscopic Cholecystectomy ◽  
Pilot Study ◽  
Bile Duct ◽  
Target Identification ◽  
Consensus Conference ◽  
Critical View ◽  
Critical View Of Safety ◽  
Video Recordings ◽  
True Value ◽  
Dissection Technique

Abstract Background Safe laparoscopic cholecystectomy(LC) depends on surgeon's experience, operative difficulty, utilisation of traditional safety markers, adapting the dissection technique and, where possible, displaying the critical view of safety (CVS) to confirm cystic pedicle structures prior to division. The Safe Cholecystectomy Multi-Society Practice Guidelines and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy identified no direct comparative evidence to support the CVS over other methods of anatomic identification. The aim of this study, therefore, was to examine the consistency of safety markers guiding the dissection and to determine the value of displaying the CVS. Methods A pilot study was conducted, reviewing video recordings of 241 LCs (144 retrospective and 97 prospective). The consistency of the Rouvier Sulcus (RS), the cystic lymph node (CLN), identification of the common bile duct (CBD) and duodenum and a new marker; the “cystic duct fold” (CDF), the peritoneal fold stretching between the retracted Hartman's Pouch and the CBD guiding the dissection at its distal end over the gallbladder neck, was documented. Data on the safety marker used to commence dissection, gallbladder condition, the LC difficulty grade, the selected technique and whether the CVS was achieved was recorded and analysed. Results Although the CBD and duodenum were visualised in 77%, the CDF was identifiable in 56% (CLN in 52.3%, RS in 50.2%) and the most consistently used to commence dissection in 51.4% (CLN 17.4%, CBD in 11.6% and RS in 6.6%). 12.8% required access to the infundibulum using sub-serosal or trans-vesical dissection (41% had acute cholecystitis, empyema or gangrenous gallbladders). Infundibular dissection was used in 88%. CVS was achievable in 56.8%. The CDF dropped form 87% in difficulty grades 1 and 2 to 16.5% in grades 4 and 5 with the CLN used in 21% of these difficult LCs. Conclusions A new safety marker, the CDF is proposed, being more reliable and safer on account of starting the dissection away from the CBD and potentially aberrant ducts, contrary to the line of RS. The CLN is more reliable in difficult LC, especially with acute inflammation. Infundibular dissection remains the default approach to “target identification” required to display the CVS. The true value of the CVS, as an end product of the process of dissection, lies in “target confirmation” before dividing any structures and in clearing the cystic plate to avoid injury to Couinaud Types C, F and hepato-cystic ducts.

scholarly journals P-BN17 Laparoscopic subtotal cholecystectomy is a safe and effective treatment for gallstone disease

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Emily Leivers ◽  
Zaher Toumi
Keyword(s):  
Hospital Admissions ◽  
Gallbladder Disease ◽  
Gallstone Disease ◽  
Bile Leak ◽  
Biliary Colic ◽  
Critical View ◽  
Critical View Of Safety ◽  
Subtotal Cholecystectomy ◽  
Calot’S Triangle ◽  
Gallbladder Surgery

Abstract Background Laparoscopic cholecystectomy is the gold standard treatment of gallstones in fit patients with symptomatic gallbladder disease. If the critical view of safety cannot be achieved intra-operatively, there are few options, one of which is laparoscopic subtotal cholecystectomy. This study aims to ascertain the outcomes of subtotal cholecystectomy. Methods Retrospective review of all patients who underwent laparoscopic subtotal cholecystectomy by a single surgeon over a 5 year period. Results 37 consecutive patients who underwent subtotal cholecystectomy were included in this study; seventeen of which were males (49%); the median age was 69, and 18 were emergencies (49%).The most common reasons for conversion to laparoscopic subtotal cholecystectomy were adhesions (57%) and fibrotic Calot’s triangle (22%). One patient required ERCP and biliary stenting for ongoing bile leak and another returned to theatre for post operative bleeding during index admission. 6 patients (16%) required further hospital admissions for gallstone disease (1 for biliary colic, two for cholecystitis and three for CBD stones). 3 patients required ERCP. None required further gallbladder surgery. Conclusions Laparoscopic subtotal cholecystectomy is a safe and effective alternative to total cholecystectomy when the critical view of safety cannot be achieved. In our experience, only a small proportion of patients have recurrent biliary problems. 

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