A 'critical view' on a classical pitfall in laparoscopic cholecystectomy!

Area of Science:

• Gastroenterology
• Surgical Innovation
• Minimally Invasive Surgery

Background:

• Laparoscopic cholecystectomy is a prevalent general surgery procedure.
• Misidentification of intraoperative anatomy is a primary cause of bile duct injuries.
• The "critical view of safety" aims to identify the cystic duct before transection.

Purpose of the Study:

• Discuss pitfalls and strategies for avoiding bile duct injury during laparoscopic cholecystectomy.
• Present a case report illustrating anatomical misperception and its resolution.
• Highlight the importance of anatomical clarity in preventing surgical complications.

Main Methods:

• A case of laparoscopic cholecystectomy in a patient with a shrunken gallbladder is presented.
• The "critical view of safety" was initially established but led to dissection of the common bile duct.
• Gallbladder mobilization was performed fundus-first to achieve better anatomical visualization.

Main Results:

• Common bile duct transection was avoided by critically re-examining the anatomy.
• Sufficient gallbladder mobilization from its bed was crucial for establishing a clear "critical view of safety".
• The procedure was successfully completed after careful dissection and identification of the cystic duct.

Conclusions:

• Bile duct injuries remain more frequent in laparoscopic compared to open surgery.
• Consistent implementation of the "critical view of safety" significantly minimizes the risk of biliary lesions.
• Adequate gallbladder mobilization is essential for achieving a "critical view of safety" in laparoscopic cholecystectomy.