Subtotal cholecystectomy with omental pedicle plug for the challenging gallbladder: A case report and review of the literature

If patient anatomy or disease does not allow for a traditional or partial cholecystectomy, an omental pedicle plug may be a viable option to limit the risk of postoperative uncontrolled bile leak from the cystic duct and to control patient symptoms.

Scale and Safety: Analyzing the Association Between Intraoperative Difficulty and Achieving the Critical View of Safety in Laparoscopic Cholecystectomy

BACKGROUND

 Laparoscopic cholecystectomy (LC) is the preferred method for gallstone removal, but bile duct injuries remain a concern. Achieving the critical view of safety (CVS) is pivotal in preventing such injuries. The aim of this study was to compare the rates of difficult LC in those with CVS achieved compared to those with CVS not achieved.

METHODS

We performed a single-center prospective study on all patients with ultrasound-confirmed symptomatic gallstones. Patients were excluded if they refused to consent or if they underwent LC for indications other than gallstone disease. Patients were stratified into two groups as CVS not achieved and CVS achieved groups and compared for outcomes. Our primary outcome was the rate of intraoperative difficulty on the modified Nassar scale (MNS). Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY).

RESULTS

We included 70 patients who underwent LC for gallstones (CVS not achieved = 24 and CVS achieved = 46). The mean (SD) age was 42.2 (12.3) years, and 73.5% were females. The mean (SD) weight in our study cohort was 74.1 (10.9) kg, and there was no difference between the two groups in terms of the baseline demographic characteristics, disease characteristics, and comorbid conditions (p > 0.05). On univariate analyses, achieving CVS was associated with lower rates of higher-grade operative difficulty on the MNS and lower rates of length of stay of more than one day.

CONCLUSION

Achieving CVS is associated with easy LC based on significantly lower Nassar scores. These findings highlight the role of the MNS in the successful identification of the operative difficulty of LC and its correlation with achieving CVS.

Three-Port Laparoscopic Cholecystectomy as a Safe and Feasible Alternative to the Conventional Four-Port Laparoscopic Cholecystectomy

Aims A prospective observational study was performed to assess the feasibility and safety of three-port laparoscopic cholecystectomy. Parameters comprising age, sex, number of cases in which intra-operative difficulty were encountered, and outcomes such as number of cases that required conversion to four-port laparoscopic cholecystectomy, postoperative pain on the visual analog scale (VAS), and postoperative hospital stay were assessed. We also documented difficult cases that were operated successfully with three ports, and the number of cases that needed conversion to four ports along with the reason for the conversion. Material and methods The patients were operated upon in the supine position in all cases. A pre-emptive analgesia with 1% lignocaine was administered in all cases prior to making the incision. The first port was 10-mm supraumbilical and inserted by the open technique. After insertion of the umbilical port, pneumoperitoneum was created by maintaining a maximum pressure of 12 mmHg and a flow rate of 8 L/minute. A camera head with a 30° telescope was introduced in the peritoneal cavity, and diagnostic laparoscopy was performed. A 10-mm subxiphoid port and a 5-mm subcostal port were placed under vision, with the latter placed more lateral and inferior to the conventional port position for better triangulation and ergonomics. The outcomes measured were operative time, the number of cases requiring a fourth port, postoperative pain (VAS), and postoperative hospital stay (number of days patients stayed in the hospital post-surgery until discharge). Data were collected using MS Excel, and an analysis was performed using SPSS Version 21.0. Results Data of 102 patients were analyzed prospectively. The mean age of the patients was 50.98 years, with an SD of 16.88, and the gender ratio was 73:29 (female: male). The mean operative time was 52.68 ± 20.84 minutes, with an SD of 20.84. Difficulty was encountered in 18.6% of cases in the form of pericholecystic adhesions, aberrant Calot's anatomy, empyema or mucocele of the gallbladder, or bleeding from the liver bed or cystic artery stump. Postoperative pain was less in our study due to the reduced number of ports and the use of a pre-emptive analgesia, with a mean VAS score of 1.22 and an SD of 0.56. The mean postoperative hospital stay was 1.08 days, with an SD of 0.31. We needed to convert to a four-port procedure for safety in 2.9% cases. The operative time and postoperative hospital stay in our study were similar to those of other studies, but our average pain score was less due to the use of the pre-emptive analgesia. Only three cases required conversion to four ports, and 99 cases were successfully managed with three ports without compromising safety. No bile duct injury occurred in any of our 102 cases. Conclusion From this study, we conclude that three-port cholecystectomy is feasible, and it can be performed even in difficult cases without compromising safety. The surgical time is similar to that of four-port cholecystectomy, and the postoperative stay is shorter. The decreased number of ports and the pre-emptive analgesia reduced postoperative pain, cosmesis was better, and the incidence of bile duct injury did not increase. The procedure can also be converted to four-port cholecystectomy at any time if safety is compromised. Therefore, three-port cholecystectomy is a viable and safe option in the treatment of gallstone disease.

Critical View of Safety Dissection and Rouviere's Sulcus for Safe Laparoscopic Cholecystectomy: A Descriptive Study

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

D-line Approach for Safe Laparoscopic Cholecystectomy: Initial Experience

Introduction The critical view of safety is an important concept for safe laparoscopic cholecystectomy. However, no standard step-by-step approach for achieving the critical view of safety has been established until now. Therefore, this study aims to evaluate a new approach for achieving the critical view of safety using the diagonal line of liver segment IV as an anatomical landmark. Patients and methods In this prospective non-randomized study, patients (n= 112) who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis were included. The first 47 patients underwent laparoscopic cholecystectomy using the diagonal line approach (DLC group) whereas, the next 65 patients underwent laparoscopic cholecystectomy using the conventional method (CLC group).  Results No significant difference between both groups regarding the preoperative characteristics, operative time, and intraoperative blood loss. Laparoscopic subtotal cholecystectomy was performed more in the DLC group (6% vs 0%, p= 0.07). Whereas, in the CLC group, there was a tendency towards conversion to open cholecystectomy in difficult cases (6% vs 2%, p= 0.40). No intra- or postoperative complications occurred in either group.  Conclusion The diagonal line approach is a feasible and useful step-by-step technique to achieve the critical view of safety in laparoscopic cholecystectomy and enables surgeons to perform safe laparoscopic subtotal cholecystectomy in difficult cases.

When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.

Anatomical variations of cystic artery, cystic duct, and gall bladder and their associated intraoperative and postoperative complications: an observational study

Anatomical variations in the calots triangle encountered during laparoscopic cholecystectomy are not uncommon. Misidentification and misperception of these structures are the major cause of vasculobiliary injuries. This study was conducted to estimate the prevalence of anatomical variations of the cystic artery, cystic duct (CD), and gall bladder. This is the first study in India to access the rate of intraoperative and postoperative complications in anatomical variants compared to normal individuals.

PATIENTS AND METHODS

It was a prospective observational study on patients undergoing laparoscopic cholecystectomy in the department of General Surgery at the tertiary center of India. The calculated sample size was 298. Variations of the cystic artery, CD, and gall bladder along with intraoperative and postoperative complications were noted. The comparative analysis of intraoperative and postoperative complications and a subgroup analysis between anatomical variants and normal patients were performed.

RESULTS

The most common variations were found in cystic arteries (16.8%). CD anomalies were present in 11.4% of patients, and gall bladder anomalies were the least common of all (5.4%). Intraoperative and postoperative complications were compared between patients with anatomical variations and normal anatomy. Intraoperative complications in patients with anatomical variations were significantly higher. Bile leak (15.7% vs. 6.4%) (P=0.01), haemorrhage (16.8% vs. 1.9%) (P-value <0.001), conversion to open (3 vs. 0 patients) (P-value =0.03). Subgroup analysis revealed a strong association between intraoperative haemorrhage and bile leak with cystic artery and CD anomalies, respectively.

CONCLUSION

Cystic artery anomalies are the most common variations. Patients with anatomical variations had significant intraoperative and postoperative complications compared to patients with normal anatomy.

Automated analysis of intraoperative phase in laparoscopic cholecystectomy: A comparison of one attending surgeon and their residents

OBJECTIVE

This study compares the intraoperative phase times in laparoscopic cholecystectomy performed by an attending surgeon and supervised residents over 10-years to assess operative times as a marker of performance and any impact of case severity on times.

DESIGN

Laparoscopic cholecystectomy videos were uploaded to Touch Surgery™ Enterprise, a combined software and hardware solution for securely recording, storing, and analysing surgical videos, which provide analytics of intraoperative phase times. Case severity and visualisation of the critical view of safety (CVS) were manually assessed using modified 10-point intraoperative gallbladder scoring system (mG10) and CVS scores, respectively. Attending and residents' times were compared unmatched and matched by mG10.

SETTING

Secondary analysis of anonymized laparoscopic cholecystectomy video, recorded as standard of care.

PARTICIPANTS

Adult patients who underwent elective laparoscopic cholecystectomy a single UK hospital. Cases were performed by one attending and their residents.

RESULTS

159 (attending=96, resident=63) laparoscopic cholecystectomy videos and intraoperative phase times were reviewed on Touch Surgery™ Enterprise and analyzed. Attending cases were more challenging (p=0.037). Residents achieved higher CVS scores (p=0.034) and showed longer dissection of hepatocystic triangle (HCT) times (p=0.012) in more challenging cases. Residents' total operative time (p=0.001) and dissection of HCT (p=0.002) times exceeded the attending's in low-severity matched cases (mG10=1). Residents' total operative times (p<0.001), port insertion/gallbladder exposure (p=0.032), and dissection of HCT (p<0.001) exceeded the attending's in matched cases (mG10=2). Residents' total operative (p<0.001), dissection of HCT (p<0.001), and gallbladder dissection (p=0.010) times exceeded the attendings in unmatched cases.

CONCLUSIONS

Residents' total operative and dissection of HCT times significantly exceeded the attending's unmatched cases and low-severity matched cases which could suggest training need, however, also reflects an expected assessment of competence, and validates time as a marker of performance.

SurgSmart: an artificial intelligent system for quality control in laparoscopic cholecystectomy: an observational study

BACKGROUND

The rate of bile duct injury in laparoscopic cholecystectomy (LC) continues to be high due to low critical view of safety (CVS) achievement and the absence of an effective quality control system. The development of an intelligent system enables the automatic quality control of LC surgery and, eventually, the mitigation of bile duct injury. This study aims to develop an intelligent surgical quality control system for LC and using the system to evaluate LC videos and investigate factors associated with CVS achievement.

MATERIALS AND METHODS

SurgSmart, an intelligent system capable of recognizing surgical phases, disease severity, critical division action, and CVS automatically, was developed using training datasets. SurgSmart was also applied in another multicenter dataset to validate its application and investigate factors associated with CVS achievement.

RESULTS

SurgSmart performed well in all models, with the critical division action model achieving the highest overall accuracy (98.49%), followed by the disease severity model (95.45%) and surgical phases model (88.61%). CVSI, CVSII, and CVSIII had an accuracy of 80.64, 97.62, and 78.87%, respectively. CVS was achieved in 4.33% in the system application dataset. In addition, the analysis indicated that surgeons at a higher hospital level had a higher CVS achievement rate. However, there was still considerable variation in CVS achievement among surgeons in the same hospital.

CONCLUSIONS

SurgSmart, the surgical quality control system, performed admirably in our study. In addition, the system's initial application demonstrated its broad potential for use in surgical quality control.

Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure

Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.

State of the art in subtotal cholecystectomy: An overview

Introduction

Subtotal cholecystectomy is a type of surgical bail-out procedure indicated when facing difficult laparoscopic cholecystectomy due to not reaching the critical view of safety, inadequate identification of the anatomical structures involved and/or risk of injury.

Materials and methods

A comprehensive search on PubMed were performed using the following Mesh terms: Subtotal cholecystectomy and Partial cholecystectomy. The PubMed databases were used to search for English-language reports related to Subtotal cholecystectomy between January 1, 1987, the date of the first published laparoscopic cholecystectomy, through January 2023. 41 studies were included.

Results

Subtotal cholecystectomy's incidence oscillates between 4.00% and 9.38%. Strasberg et al., divided subtotal cholecystectomies in "fenestrating" and "reconstituting" types based on if the remaining portion of the gallbladder was left open or closed. Subtotal cholecystectomy can sometimes be a challenging procedure and is associated to a high rate of complications such as biliary fistula, retained gallstones, subhepatic or subphrenic collections, among others.

Conslusion

Subtotal cholecystectomy is a safe alternative when facing difficult cholecystectomy in which the critical view of safety is not reached in order to avoid complications. A classification system should be implemented in surgical descriptions to compare the different surgical techniques employed. In order to avoid bile leakage and cholecystitis of the remnant gallbladder, the surgical technique must be performed skillfully. There is still a current lack of information on alternative techniques such as omental plugging or falciform patch in order to judge their utility. There needs to be further research on long-term complications such as malignancy of the remnant gallbladder.

[Integration of ICG-fluorescence cholangiography into the safety system of laparoscopic cholecystectomy]

THE AIM OF THE STUDY

Is evaluating the possibility of integrating ICG-fluorescent cholangiography into the general safety system for laparoscopic cholecystectomy to prevent damage to the extrahepatic bile ducts by working out the methodological aspects of navigation technologies.

MATERIALS AND METHODS

The analysis of literature data on various approaches to improve the perioperative identification of anatomical structures during laparoscopic cholecystectomy, including the ICG-fluorescent cholangiography, was carried out. This program was implemented during the provision of elective surgical care to 24 patients with cholelithiasis who underwent laparoscopic cholecystectomy with ICG-fluorescent navigation.

RESULTS AND DISCUSSION

The developed program included: preoperative assessment of the anatomy of the biliary tree using MRCP; intraoperative technique of safe laparoscopic cholecystectomy with mandatory application of the concept of «critical view of safety» (CVS), which allows the most effective identification of the necessary anatomical structures; the use of ICG-fluorescent cholangiography, which allows to improve the control of anatomical structures at all stages of the operations.

CONCLUSIONS

The first experience of using ICG-fluorescent cholangiography testifies to the high informative value of the method, the possibility and prospects of integrating the technology into a comprehensive safety system during laparoscopic cholecystectomy.

Iatrogenic Injury of Biliary Tree-Single-Centre Experience

Cholecystolithiasis is among the most prevalent gastrointestinal disorders requiring surgical intervention, and iatrogenic damage to the bile tree is a severe complication. We aimed to present the frequency of bile duct injuries and how our facility handles these complications. We retrospectively analyzed bile duct injuries in patients undergoing surgery. We concentrated on factors such as sex, age, indications for surgery, type of surgery, primary procedure, bile tree injury, repair, and timing as well as early and late complications. There were 22 cases of bile duct injury in the studied material, primarily affecting women-15 individuals (68.2%). Eleven cases (45.7%) of acute cholecystitis were the primary reason for surgery, and an injury to the common bile duct that extended up to 2 cm from the common hepatic duct was the most common complication (European Association for Endoscopic Surgery grade 2). Roux-en-Y hepaticojejunostomy was the most common repair procedure in 14 cases (63.6%). Eleven patients (50%) experienced early complications following reconstruction surgery, whereas five patients (22.7%) experienced late complications. An annual mortality rate of 22.7% (five patients) was observed. Iatrogenic bile duct injury is a severe complication of surgical treatment for cholecystolithiasis. Reconstruction procedures are characterized by high complication rates and high mortality.

[Modern principles of safety in laparoscopic cholecystectomy]

Laparoscopic cholecystectomy has many advantages over open surgery. Nevertheless, incidence of intraoperative bile duct injury is consistently higher for laparoscopic technique. This review is devoted to modern principles of identifying the anatomical elements in hepatoduodenal ligament and rules for safe tissue dissection in this area. The last ones mainly consist in formation of «critical view of safety» before clipping and transection of tubular structures. The key for «critical view of safety» is mobilization of fatty and fibrous tissues of hepatocystic triangle starting from the lower third of the gallbladder.

Enormous Gallstone Discovered in the Setting of Acute-on-chronic Cholecystitis

Biliary disease is a common surgical problem. A unique case of a 53-year-old male with an enormous gallstone precluding safe laparoscopic cholecystectomy is presented. The patient was a 53-year-old male who presented to the emergency department with a 1-day history of abdominal pain for which clinical findings were consistent with acute cholecystitis. A laparoscopic cholecystectomy was attempted, but could not be safely completed due to an enormous gallstone prohibiting attainment of the critical view of safety. The stone measured 12.2 cm × 5.2 cm × 5.2 cm. Although biliary disease is very common and its management well documented, it is rare to uncover stones larger than 5 centimeters in diameter. Clinicians should be aware that enormous gallstones require prompt surgical intervention if discovered in the elective setting to minimize future morbidity should cholecystitis develop; early elective cholecystectomy should be considered upon discovery of large gallstones to prevent encountering a gallbladder with decreased mobilization in the setting of inflamed tissues.

Assembling a library of typical surgery video clips to construct a system for assessing the surgical difficulty of laparoscopic cholecystectomy

BACKGROUND

To explore best practices for acute cholecystitis, it is necessary to construct a system to assess the difficulty of laparoscopic cholecystectomy (LC) based on intraoperative findings. In this study, multiple evaluators assessed videos of LC to assemble a library of typical video clips for 25 intraoperative findings.

METHODS

We have previously identified 25 items that contribute to surgical difficulty in LC. For each item, roughly 30-second video clips were submitted from videos of LC performed at member institutions. We then selected one typical video from the collected clips based on simple tabulation of the instances of agreement. Inter-rater agreement was assessed with Fleiss's κ and Gwet's agreement coefficient (AC).

RESULTS

Except in the case of two assessment items ("edematous change" and "easy bleeding"), κ or AC significantly exceeded 0.5 and the typical videos were judged to be applicable. For the two remaining items, the evaluation was repeated after clarifying the definitions of positive and negative findings. Eventually, they were recognized as typical. The completed video clip library contains 31 clips and is divided into five categories (http://www.jshbps.jp/modules/project/index.php?content_id=13).

CONCLUSIONS

This clip library may be highly useful in clinical settings as a more objective standard for assessing surgical difficulty in LC.

Transillumination of Calot's Triangle on Laparoscopic Cholecystectomy: A Feasible Approach to Achieve a Critical View of Safety

Background

Laparoscopic cholecystectomy is currently one of the most commonly performed procedures globally. Morbidity of laparoscopic cholecystectomy is low; however, bile duct injury is still a feared complication. Despite worldwide efforts, the global incidence of bile duct injury remains higher for laparoscopic cholecystectomy compared with open cholecystectomy. Despite the general belief that the learning curve and lack of laparoscopic skills represent the most common causes of bile duct injuries, the principal cause is the misidentification of biliary anatomy. The aim of our study is to determine if laparoscopic transillumination is a feasible approach to bile and vascular structures visualization during laparoscopic cholecystectomy because the only other method for real-time visualization is fluorescent cholangiography, which can be cost-prohibitive and requires specialized equipment and training.

Materials and methods

We performed a retrospective comparison of outcomes between the transillumination approach in 10 patients receiving laparoscopic cholecystectomy (group A) and a control group of 50 conventional laparoscopic cholecystectomy patients (group B). We compared demographic data, type of surgery, operative time, bleeding, intraoperative and postoperative complications, and hospital stay. We used a conventional four-port positioning for laparoscopic cholecystectomy, and a 5-mm/30° scope was used as a light source and placed behind the area identified as Calot’s triangle.

Results

Group A consisted of 10 patients (9 women, 1 man), with a mean age of 50.7 (± 17.4) years. The mean body mass index (BMI) in group A was 26.8 (± 0.65) kg/m². In group A, three of the cholecystectomies were conducted as emergency procedures. Group B consisted of 50 patients (40 women, 10 men), with a mean age of 49.7 (±15.2) years. The mean BMI in group B was 27.5 (±4.5) kg/m², and two cholecystectomies were emergency procedures. In comparing the transillumination approach with conventional cholecystectomy, we found no statistical differences in operative time, bleeding, complications, or mean hospital stay.

Conclusions

Laparoscopic transillumination is a feasible method for real-time visualization of Calot’s triangle structures. Our initial experience with transillumination did not provide better outcomes than conventional cholecystectomy.

Segment IV approach for difficult laparoscopic cholecystectomy

Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D-line) as a feasible landmark for carrying out difficult LC. The D-line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D-line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty-two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D-line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D-line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54-290) min and 10 (range, 0-100) mL, respectively. No intra- or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.

A gallbladder with the "hidden cystic duct": A brief overview of various surgical techniques of the Calot's triangle dissection

We present a case of a middle-aged female who attended for a routine laparoscopic cholecystectomy as a day case surgery. At operation, she was found to have a distended gallbladder with an unusually prominent distal portion. This has made the dissection of the Calot's triangle challenging. As a result, the "critical view of safety" technique was applied. This allowed for the clear Calot's triangle visualization and identification of the cystic duct and artery. This case highlights that the knowledge of various ways of the cystic duct dissection is essential to every surgeon. Furthermore, this helps to adjust the dissection approach on an individual case bases ensuring avoidance of the common bile duct injuries.