What is the best technique for displaying correct anatomy during laparoscopic cholecystectomy to avoid biliary injury?

Best Technique for Displaying Correct Anatomy During Laparoscopic Cholecystectomy

The best technique for displaying correct anatomy during laparoscopic cholecystectomy to avoid biliary injury is lateral retraction of the gallbladder infundibulum. Lateral traction on the infundibulum of the gallbladder places the cystic duct perpendicular to the common bile duct, providing optimal visualization of the critical anatomy and reducing the risk of bile duct injury. 1

Critical View of Safety (CVS) Technique

The Critical View of Safety (CVS) technique is the recommended approach for laparoscopic cholecystectomy to minimize iatrogenic complications:

• CVS was introduced in 1995 to promote recognition of gallbladder elements, particularly the hepatocystic triangle (composed of the cystic duct, common bile duct, and liver) 2
• When properly identified, CVS significantly minimizes the risk of iatrogenic intraoperative complications 2
• Routine use of CVS is recommended over other techniques, such as the infundibular approach 2
• The CVS technique requires:
  • Clearance of the lower third of the gallbladder from the liver bed 2
  • Identification of only two structures entering the gallbladder (cystic duct and cystic artery) 2
  • Lateral retraction of the infundibulum to properly expose these structures 1

Proper Retraction Technique

Lateral retraction of the gallbladder infundibulum offers several advantages:

• Places the cystic duct perpendicular to the common bile duct, reducing misidentification risk 1
• Reduces redundancy in the infundibulum and best exposes the cystic duct 1
• Allows for dissection of the cystic duct at the infundibulum of the gallbladder 1
• Helps establish the critical view of safety more effectively 2, 1

Alternative Approaches When CVS Cannot Be Achieved

When the critical view of safety cannot be established despite proper retraction:

• Consider "fundus-first (top-down)" approach or subtotal cholecystectomy (STC) 2
• The fundus-first technique is associated with reduced rates of conversion and iatrogenic complications during difficult operations 2
• Intraoperative cholangiography (IOC) may be used to recognize choledocholithiasis and define biliary anatomy, particularly when anatomy is unclear 2
• Indocyanine green fluorescence cholangiography (ICG-C) can visualize biliary structures without X-ray imaging 2

Common Pitfalls and Prevention

• Bile duct injury (BDI) occurs in approximately 0.1% of elective laparoscopic cholecystectomies and 0.3% of emergency procedures 2
• Misidentification of the cystic anatomy is the main cause of bile duct injury 3
• Certain gallbladder infundibulum positions (3-o'clock and 12-o'clock) are potential pitfalls that might cause biliary injury 3
• Posterior infundibular dissection as an initial operative maneuver has been reported to reduce BDI risk 4
• If proper anatomical orientation cannot be achieved despite lateral retraction, conversion to open cholecystectomy should be considered 1

High-Risk Scenarios

• Acute cholecystitis increases BDI risk due to local inflammation 2
• Scleroatrophic cholecystitis and Mirizzi syndrome are high-risk conditions requiring careful preoperative workup 2, 5
• Male sex, age > 60 years, obesity, cirrhosis, previous upper abdominal surgery, large bile stones, and elevated bilirubin levels increase the risk of difficult cholecystectomy 2
• Early intervention (within 72 hours to 10 days) is recommended for acute cholecystitis to prevent disease progression and unfavorable conditions 2