Subscribe to RSS
DOI: 10.1055/s-0042-1744154
Critical View of Safety in Laparoscopic Cholecystectomy: A Word of Caution in Cases of Aberrant Anatomy
Abstract
Introduction To avoid vasculobiliary injuries, the Critical View of Safety (CVS) technique is strongly recommended during dissection of the hepatocystic triangle. It entails three basic steps as follows: (1) complete clearance of the hepatocystic triangle of fibrofatty tissue, (2) separation of the lower part of the gallbladder from the cystic plate, so that (3) two and only two structures are seen entering the gallbladder.
Case History In this video vignette, we present the case of an aberrant hepatic artery, coursing subserosally parallel to the gallbladder wall. Despite presumably achieving all three CVS requirements, the surgeon did not proceed to clipping and dividing the two structures, preventing a major vascular injury. Due to its unusually large caliber, the artery was carefully dissected, and multiple smaller branches to the gallbladder were ligated instead, until it was definitively identified entering into the hepatic parenchyma of segments IVb–V.
Discussion The CVS approach was originally conceived as a means for the conclusive recognition of the cystic duct and artery to prevent misidentification errors. However, in such cases of extreme anatomical variations, the CVS may indeed have certain limitations. Therefore the surgeon should always maintain a high degree of suspicion and a low threshold for alternative bail-out options.
Publication History
Received: 27 October 2021
Accepted: 27 January 2022
Article published online:
18 October 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Ahmad DS, Faulx A. Management of postcholecystectomy biliary complications: a narrative review. Am J Gastroenterol 2020; 115 (08) 1191-1198
- 2 Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180 (01) 101-125
- 3 Andall RG, Matusz P, du Plessis M, Ward R, Tubbs RS, Loukas M. The clinical anatomy of cystic artery variations: a review of over 9800 cases. Surg Radiol Anat 2016; 38 (05) 529-539
- 4 Michels NA. Variational anatomy of the hepatic, cystic, and retroduodenal arteries; a statistical analysis of their origin, distribution, and relations to the biliary ducts in two hundred bodies. AMA Arch Surg 1953; 66 (01) 20-34
- 5 Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg 2010; 211 (01) 132-138
- 6 Strasberg SM. A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review. J Hepatobiliary Pancreat Sci 2019; 26 (04) 123-127
- 7 Broderick RC, Lee AM, Cheverie JN. et al. Fluorescent cholangiography significantly improves patient outcomes for laparoscopic cholecystectomy. Surg Endosc 2021; 35 (10) 5729-5739
- 8 Nijssen MA, Schreinemakers JM, Meyer Z, van der Schelling GP, Crolla RM, Rijken AM. Complications after laparoscopic cholecystectomy: a video evaluation study of whether the critical view of safety was reached. World J Surg 2015; 39 (07) 1798-1803
- 9 Shimoda M, Udo R, Imasato R, Oshiro Y, Suzuki S. What are the risk factors of conversion from total cholecystectomy to bailout surgery?. Surg Endosc 2021; 35 (05) 2206-2210
- 10 Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 1993; 165 (01) 9-14
- 11 Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 2011; 13 (01) 1-14
- 12 Yamazaki S, Takayama T, Yoshida N. et al. Aberrant anterior branch of segment V traveling ventrally across the gallbladder: a case of critical anatomy. Surg Radiol Anat 2020; 42 (12) 1479-1481
- 13 Blecha MJ, Frank AR, Worley TA, Podbielski FJ. Aberrant right hepatic artery in laparoscopic cholecystectomy. JSLS 2006; 10 (04) 511-513
- 14 Manatakis DK, Papageorgiou D, Antonopoulou M-I. et al. Ten-year audit of safe bail-out alternatives to the critical view of safety in laparoscopic cholecystectomy. World J Surg 2019; 43 (11) 2728-2733
- 15 Sebastian M, Rudnicki J. Recommendation for cholecystectomy protocol based on intraoperative ultrasound - a single-centre retrospective case-control study. Wideochir Inne Tech Malo Inwazyjne 2021; 16 (01) 54-61
- 16 Schols RM, Bouvy ND, van Dam RM, Masclee AA, Dejong CH, Stassen LP. Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy. Surg Endosc 2013; 27 (12) 4511-4517
- 17 Manatakis DK, Tasis N, Antonopoulou MI. et al. Morphology of the sulcus of the caudate process (Rouviere's sulcus) in a Greek population and a systematic review with meta-analysis. Anat Sci Int 2022; 97 (01) 90-99
- 18 Gupta V, Jain G. Safe laparoscopic cholecystectomy: adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg 2019; 11 (02) 62-84
- 19 Conrad C, Wakabayashi G, Asbun HJ. et al. IRCAD recommendation on safe laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci 2017; 24 (11) 603-615
- 20 Iwashita Y, Hibi T, Ohyama T. et al. Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?. J Hepatobiliary Pancreat Sci 2017; 24 (11) 591-602