Page 21 - WJOLS - Laparoscopic Journal

WJOLS

10.5005/jp-journals-10007-1112
REVIEW ARTICLE Laparoscopic Cholecystectomy: Fundus First or Fundus Last—Which and Why?
Laparoscopic Cholecystectomy: Fundus First or

Fundus Last—Which and Why?

Moatassim Barham
Member, Jordanian Association of Surgeons, Fellow, The Global Open University in Laparoscopic Surgery, Member, World
Association of Laparoscopic Surgery, General and Laparoscopic Surgeon, Amman, Jordan

ABSTRACT
Biliary tract injury represents the most serious and potentially life-threatening cholecystectomy complication. It is important to identify the
structure of Calot’s triangle during isolation of cystic duct to decrease this injury. Cystic duct isolation is the first dangerous technique
in laparoscopic cholecystectomy. Retrograde (fundus first) dissection is frequently used in open cholecystectomy and although feasible
in laparoscopic cholecystectomy, it has not been widely practiced as the antegrade conventional one. This article is presented to show
that retrograde method appears to be a safe procedure and does not compromise the conventional one. It should be tried if obscure
anatomy should occur without proceeding to irreparable hemorrhage or biliary injury. If these do occur, conversion is always a viable
choice and should not be deemed a failure. However, retrograde dissection remains to have its error trap that is mostly leading to
vasculobiliary injuries as well as the drawback of retained GB stones tendency.
Abbreviations: OC: Open cholecystectomy, LC: Laparoscopic cholecystectomy, RLC: Retrograde laparoscopic cholecystectomy,
CLC: Conventional laparoscopic cholecystectomy, GB: Gallbladder, CBD: Common bile duct, CHD: Common hepatic duct, IOC:
Intraoperative cholangiography, ERCP: Endoscopic retrograde cholangiopancreaticography.
Keywords: Fundus-first, Fundus-down, Retrograde, Antegrade, Conventional, Laparoscopic cholecystectomy.

INTRODUCTION maneuvers to isolate the cystic duct or to free GB from
Iatrogenic biliary injuries have increased in incidence in the CBD. These maneuvers may be more difficult and
first decade with the introduction of LC. The incidence of consequently more dangerous when there is significant
major biliary injury is 0.25 to 0.74% and of minor injury is inflammation as may be seen in acute cholecystitis or in
1
0.28 to 1.7%. Although a number of factors have been case of obesity, cirrhosis with portal hypertension, previous
identified as high risk and a number of technical steps have surgery with peritoneal adhesions or anatomic variations of
been emphasized to avoid these injuries, the incidence of the hepatic pedicle. This article is presented to investigate
CBD injury has reached atleast double the rate observed the place of RLC showing the advantages and disadvantages
with OC. Cholecystectomy is the most frequently performed and comparing it with CLC via many different parameters,
abdominal operation and the most serious complication especially biliary tract injury.
associated with this procedure is accidental injury to CBD
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(0.3-0.4%). Preventable technical errors have traditionally AIMS AND OBJECTIVES
been thought to occur in one or more of the three situations: The aim of this study is to compare the effectiveness and
a. When the operator attempts to clip or ligate a bleeding safety among many other parameters assessed of RLC
cystic artery and CHD, (up-down) vs CLC (down-up). The following parameters
b. When too much traction has been exerted on GB, so
that CBD has tented up into an elbow which was either were evaluated:
tied off with ligature or clipped, • Patient selection methods
c. When anatomic anomalies were not recognized and the • Operative techniques
wrong structure is divided. • Operative time
The use of the safest surgical technique (not the fastest) • Incidence of biliary injury
available, such as the critical view technique of Strasberg • Complications
et al with the circumferential dissection of GB at the • Rate of conversion
infundibulum to mimic RLC technique of the open era and • Hospital stay and cost effectiveness
not clipping or cutting any structure before unequivocal • Learning curve.
identification of the structure are mandatory components
of the safe LC. 3 MATERIALS AND METHODS
The cause of the injury is not always clearly identifiable. A literature search was performed by using Google and
In more than half of the cases, the injury occurs during Online Springer Library facilities available at World

World Journal of Laparoscopic Surgery, January-April 2011;4(1):25-29 25