Page 18 - World Association of Laparoscopic Surgeons - Journal

Srijan Malla

A B
Figs 3A and B: (A) Critical view of safety (CVS) is seen from in front of the gallbladder as usually shown, (B) CVS is
seen with the gallbladder reflected to the left, so that a posterior view of the triangle of Calot is shown 22

in the remaining where it was not obtained, conversion to structure was delineated in all 52 patients studied using the
open surgery was done. 22 fluorescent imaging system. However, the cost involved is
Another method of conclusive identification of cystic a deterrent for widespread use. Similarly, Sari et al proposed
structures is by routine intraoperative cholangiogram. injecting methylene blue in the gallbladder after aspirating
Several prospective studies have tried to evaluate the the bile with a Varess needle before starting dissection. 27
usefulness of IOC in preventing CBD injury. A meta- To overcome the problem of anatomical orientation,
analysis of 40 case series detailing 327,523 LCs and 405 before starting dissection, identification of fixed anatomical
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major injuries was performed in 2002. Rate of injury was landmarks is helpful. Hugh recommends identifying
halved in the routine IOC group (0.21%) as compared with Rouviere’s sulcus as a fixed extrabiliary point ventral to
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the selective group (0.43%). In addition, in the selective the right portal pedicle. Dissection ventral to this allows
group, only 21.7% of CBD injuries were detected a triangle of safe dissection when the gallbladder has been
intraoperatively. Fletcher et al found that routine IOC reflected cephalad. Extending this dissection as far as
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reduced the incidence of injury. The study method adjusted possible up the gallbladder fossa both posteriorly and
for confounding variables, such as age, sex, hospital type anteriorly allows the hepatobiliary triangle to open out. This
and severity of disease. One argument against ensures no unexpected anatomy and confirms the correct
cholangiography is, if the CBD is misidentified while an anatomical position before any significant structure is
IOC is being performed, the ductotomy created for divided.
placement of the IOC catheter is itself a CBD injury. In cases of difficulties due to severe adhesion of the
However, other studies suggest that the severity, but not gallbladder to surrounding and severe fibrosis, some have
the incidence of biliary injury is reduced by routine IOC. advocated using laparoscopic subtotal cholecystectomy as
Operative cholangiography is best at detecting an alternative to conversion as equal difficulty in dissection
misidentification of the common bile duct as the cystic duct would be required in the open surgery as well. They claim
and will prevent excisional injuries of bile ducts, if the that conversion does not guarantee the avoidance of
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cholangiogram is correctly interpreted. In an analysis of inadvertent biliary or vascular injury. Tian et al in 2009,
252 bile duct injuries during cholecystectomy, Way et al reported performing laparoscopic subtotal cholecystectomy
reported that 43 IOCs demonstrated a bile duct injury, but in 48 difficult cases out of 1558 laparoscopic cholecystec-
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only nine were correctly interpreted at the time of tomies without any serious bile duct injuries.
operation. 25
Human Factors and Bile Duct Injury
Recently, other techniques proposed to correctly identify
biliary anatomy include the use of dyes. Ishizawa et al Although thorough instruction in the principles of safe
reported using fluorescent cholangiography technique using surgical technique for cholecystectomy is essential, it may
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the intravenous injection of indocyanine green. The biliary be equally important to develop new training strategies that
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