Open-access technique and "critical view of safety" as the safest way to perform laparoscopic cholecystectomy

The 2 main challenges of laparoscopic cholecystectomy are primary peritoneal access and safe identification, ligation, and division of the cystic duct and cystic artery.

This is a 13-year period retrospective study from January 2000 to December 2012. All the operations were performed by 1 surgeon and all the data were collected from the hospitals archive. A total of 929 laparoscopic cholecystectomies were performed for symptomatic cholelithiasis. The first author was involved in all the operations either by performing or assisting in them. The open access (OA) technique was used in all cases for the creation of pneumoperitoneum. After establishing the pneumoperitoneum, the "critical view of safety" (CVS) technique was used to ligate and divide the cystic duct and cystic artery. When the OA was not possible or CVS was not feasible, the operation was converted to open.

Successful establishment of pneumoperitoneum with OA was possible in 911 of 929 (98.06%) patients and CVS was achieved in 873 patients (95.82%). In 18 patients the operation was converted to open because of dense adhesions not permitting the establishment of the pneumoperitoneum. No intraoperative or postoperative complications occurred in these patients. No bile duct injury occurred in this series. Postoperative complications were recorded in 19 patients (2.04%). Five patients had bleeding from port sites, 12 patients had wound infection at the umbilical incision, and 2 patients developed subhepatic collections, which were drained percutaneously under computed tomographic guidance.

In this series of laparoscopic cholecystectomies, we used the "open access" technique to create pneumoperitoneum and we obtained the "critical view of safety" for the identification of the cystic duct. Our results show that this approach is the safest way to perform and teach laparoscopic cholecystectomy.