The inferior boundary of dissection as a novel landmark for safe laparoscopic cholecystectomy

Since the introduction of laparoscopic cholecystectomy over 30 years ago, rates of bile duct injury have remained elevated compared to the era of open cholecystectomy. We propose an anatomical landmark, the Inferior Boundary of Dissection, to help prevent dangerous dissection in the porta hepatis and provide clues as to when a critical view of safety may not be immediately achieved.

This landmarking approach is based on fundamentals of biliary anatomy and surface landmarks of the liver.

The 'Boundary' extends from Rouviere's sulcus to the junction of the peritoneum and fat overlying the cystic and hilar plates, near the base of segment 4. This anatomic landmark represents the lower boundary for safe dissection, by outlining the location of the biliary pedicles.

The two points of reference are reliable surface landmarks with predictable and consistent relationships to the biliary pedicles. It also serves as a line above which the gallbladder can be opened or mobilized in a 'top-around' approach, facilitating subtotal cholecystectomy when the hepatocystic triangle appears hostile due to inflammation. The landmark has been well-received in our region as a facile instrument for safe cholecystectomy and we advocate for its broader use.