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

Cephalad retraction of the gallbladder infundibulum (option D) is the best technique for displaying correct anatomy during laparoscopic cholecystectomy to avoid biliary injury. 1

Critical View of Safety Technique

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

• CVS promotes proper recognition of gallbladder elements, particularly the hepatocystic triangle 2
• When properly identified, CVS significantly minimizes the risk of iatrogenic intraoperative complications 2
• The technique requires clearance of the lower third of the gallbladder from the liver bed 2
• Proper retraction is essential for establishing the Critical View of Safety 2

Optimal Retraction Technique

Cephalad (upward) retraction of the gallbladder infundibulum provides several advantages:

• Cephalad retraction allows for adequate identification of key anatomical landmarks and safer dissection in the area 1
• This technique helps to properly expose the hepatocystic triangle for visualization of the cystic duct and cystic artery 2
• Cephalad retraction minimizes trauma to the inflamed, tense gallbladder tissue while maximizing exposure 1
• This approach helps prevent misidentification of the common bile duct as the cystic duct, which is a leading cause of bile duct injury 3

Pitfalls of Other Retraction Techniques

• Lateral or medial retraction (options A and C) may distort the anatomy of the hepatocystic triangle, potentially leading to misidentification of structures 4
• According to research, certain gallbladder infundibulum positions (3-o'clock and 12-o'clock) are pitfalls that might cause biliary injury 4
• Caudad retraction (option B) can obscure the critical view by pushing the infundibulum downward, making it difficult to identify the junction between the cystic duct and common bile duct 4

Risk Factors and Prevention of Bile Duct Injury

• Bile duct injury (BDI) occurs in approximately 0.1% of elective laparoscopic cholecystectomies and 0.3% of emergency procedures 2
• Laparoscopic cholecystectomy has 2-3 times higher incidence (0.4-0.6%) of bile duct injury compared to open cholecystectomy (0.125-0.3%) 5
• Acute cholecystitis increases BDI risk due to local inflammation 2
• 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

Alternative Approaches When Standard Technique Fails

• Consider "fundus-first (top-down)" approach or subtotal cholecystectomy when the critical view of safety cannot be established despite proper retraction 2
• Posterior infundibular dissection has been reported as an alternative safe approach that lessens the need for medial and cephalad dissection 6
• Intraoperative cholangiography (IOC) may help recognize choledocholithiasis and define biliary anatomy when standard visualization is inadequate 2, 7
• Indocyanine green fluorescence cholangiography (ICG-C) can visualize biliary structures without X-ray imaging 2