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Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy
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Segment IV approach for difficult laparoscopic cholecystectomy.

Hiroaki Kitamura1, Shuichi Fujioka1, Taigo Hata1

  • 1Department of Surgery The Jikei University Kashiwa Hospital Chiba Japan.

Annals of Gastroenterological Surgery
|April 8, 2020
PubMed
Summary

The segment IV approach offers a new landmark for difficult laparoscopic cholecystectomy (LC), aiding critical view of safety (CVS) achievement. This method is feasible for both total and subtotal cholecystectomy in challenging cases.

Keywords:
critical view of safetygallbladderlaparoscopic cholecystectomysegment IV of the liversubtotal cholecystectomy

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Area of Science:

  • Hepatobiliary Surgery
  • Minimally Invasive Surgery
  • Surgical Anatomy

Background:

  • Achieving the critical view of safety (CVS) during laparoscopic cholecystectomy (LC) is crucial for preventing bile duct injuries.
  • Severe cholecystitis can present technical challenges, making CVS difficult to obtain.
  • Alternative landmarks are needed for safe execution of LC in complex cases.

Purpose of the Study:

  • To introduce and evaluate the feasibility of the segment IV approach using the D-line as a landmark for difficult laparoscopic cholecystectomy.
  • To assess the efficacy of the segment IV approach in achieving CVS and enabling both total and subtotal cholecystectomy.

Main Methods:

  • The segment IV approach utilizes the diagonal line (D-line) of liver segment IV as a dissection landmark.
  • Sixty-two consecutive difficult LC cases were managed using the segment IV approach.
  • Cases included those scheduled after PTGBD and conservatively treated TG grade II cholecystitis.

Main Results:

  • Successful gallbladder extraction with CVS achieved in 71% (44/62) of cases via total cholecystectomy.
  • 29% (18/62) of cases were converted to subtotal cholecystectomy due to severe inflammation and adhesions.
  • No intraoperative or postoperative complications were reported, with a median operative time of 135 minutes.

Conclusions:

  • The segment IV approach provides a feasible landmark for difficult LC, facilitating CVS achievement.
  • This technique allows for conversion to subtotal cholecystectomy when necessary due to severe gallbladder wall scarring.
  • The segment IV approach is a safe and effective strategy for managing complex laparoscopic cholecystectomy cases.