Anatomical appraisal of safe cholecystectomy: a prospective study

Principles of safe cholecystectomy include dissection of the hepatocystic triangle and identification of the bilio-vascular structures to achieve critical view of safety. The aim of the present study was to document the variations in anatomical landmarks and bilio-vascular structures exposed during laparoscopic cholecystectomy.

All consecutive patients who underwent laparoscopic cholecystectomy were included in the study. Recommended techniques of safe cholecystectomy were followed. Rouviere's sulcus was classified into four types. Cystic duct was assessed for its length and diameter. A new classification was suggested for cystic artery.

Five hundred patients were included in the study. Critical view of safety was achieved in 463 (92.6%) patients. Type1 Rouviere's sulcus was the most common variant found in 263 (52.6%). Normal cystic duct was present in 339 (67.8%). Wide cystic duct of normal length was the most common variant found in 71 (14.2%). Single cystic artery supero-medial to cystic duct (type1-s) was the most common variant found in 384 (76.8%). Inferior cystic artery i.e. artery infero-lateral to cystic duct (type-2) was the second most common variant, found in 40 (8%). Multiple cystic arteries in the hepatocystic triangle were due either to early division of single cystic artery (type-1m) or double cystic artery (type-3). Aberrant right hepatic artery giving off a small cystic artery (type-4) was seen in 12 (2.4%).

Wide variation in the anatomical structures is noted when principles of safe laparoscopic cholecystectomy is followed. Awareness is paramount to avoid bilio-vascular injury during surgery.