Anaotmical variability in the position of cystic artery during laparoscopic visualization

The laparoscopic view of extrahepatic biliary tract and cystic artery is different anatomically from open approach. Consequently iatrogenic injuries due to inadverent damage to cystic artery are not uncommon. These complications can be prevented by careful dissection in Calots triangle and better knowledge of laparoscopic anatomy of cystic artery and its variations. The aim of this study is to establish the prevalence of variation in position of cystic artery in relation to cystic duct. This will help identify the safe area for dissecting peritoneum in Calots triangle and thus help young surgeons overcome the long learning curve associated with laparoscopy.

During a 10 year period from January 2009 to January 2019, 1850 laparoscopic cholecystectomies that were performed at a tertiary care hospital were studied. Patients with history of previous abdominal surgery were excluded from the study. Cystic artery was divided into four groups based on its relative position to cystic duct. It includes superomedial, superolateral, anterior and absent cystic artery relative to the cystic duct.

Out of 1850 cases of laparoscopic cholecystectomy 1676 (90.59%) patients had cystic artery superomedial to cystic duct and 96 (5.19%) had a cystic artery at superolateral position to cystic duct. In 48 (2.59%) patients it was found anterior to cystic duct and in 30 (1.62%) patients it was absent.

It is concluded that the most common position of cystic artery is superomedial while the least common position was found to be anterior to cystic duct. Hence it is postulated that blind dissection from anterior side is the safest approach to avoid injury to cystic artery.