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RESEARCH ARTICLE
Adopting “Culture of Safety for Laparoscopic

Cholecystectomy” in a Rural Hospital: A Prospective

Observational Study

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Mohd Riyaz Lattoo , Prince Ajaz Ahmad , Sadaf Ali Bangri 3
AbstrAct
Background: The most feared complication of laparoscopic cholecystectomy is injury to bile duct. Different strategies have been proposed to
avoid this serious complication. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) “Culture of Safe Cholecystectomy” is
one such strategy.
Aim: This study was done to evaluate and validate SAGES “Culture of Safe Cholecystectomy” components modified and tailored to the setting
of a rural hospital with emphasis on a bystander surgeon.
Materials and methods: This was a prospective study of 382 patients with gallstone disease who underwent surgery at District Hospital,
Anantnag, a rural hospital from September 2016 to September 2018.
Results: Mean age of patients was 43 years. Two-hundred and ninety-eight (78%) patients were females, and 84 (22%) were male with male
female ratio of 1:3.54. Most common indication was chronic cholecystitis in 213 patients (55.7%). Bystander surgeon was present in all cases.
Critical view of safety (CVS) was achieved in 256 patients (67%). Rouviere’s sulcus was present in 242 patients (63.3%). Bailout option was
adopted in 19 patients (4.97%). Conversation to open cholecystectomy was done in 11 of the 382 patients (2.87%). Most common indication
for conversion was inability to achieve CVS. Mean duration of surgery was 45 minutes. None of the patients in our study had bile duct injury.
Conclusion: SAGES culture of safe cholecystectomy can be modified to make it applicable to rural hospitals in developing countries where
more reliance can be put on a detached bystander surgeon who is likely available in the vicinity.
Keywords: Bile duct injury, Calot’s triangle, Common bile duct, Cholangiography, Cholelithiasis, Laparoscopic cholecystectomy.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1470

IntroductIon 1–3 Department of Surgical Gastroenterology, Sher-I-Kashmir Institute
In modern surgical practice, laparoscopic cholecystectomy (LC) of Medical Sciences, Srinagar, Jammu and Kashmir, India
is the most frequent surgical procedure performed on digestive Corresponding Author: Mohd Riyaz Lattoo, Department of Surgical
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tract worldwide. It is considered to be the procedure of choice Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences,
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for the treatment of symptomatic gallstone disease. Iatrogenic Srinagar, Jammu and Kashmir, India, Phone: +91 9419049425, e-mail:
bile duct injury (BDI) is the most concerning complication after riyazlattoo@gmail.com
LC. The incidence of this complication is variable but usually How to cite this article: Lattoo MR, Ahmad PA, Bangri SA. Adopting
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approaches 0.5%. BDI continues to happen, and despite advances “Culture of Safety for Laparoscopic Cholecystectomy” in a Rural
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in technology, there has been no decline in rate of injury. About Hospital: A Prospective Observational Study. World J Lap Surg
97% of iatrogenic biliary ductal injury are attributed to visual 2021;14(3):191–194.
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misinterpretation of biliary anatomy during the procedure. Many Source of support: Nil
strategies have been proposed to avoid this serious complication. Conflict of interest: None
Society of American Gastrointestinal and Endoscopic Surgeons’
(SAGES) culture of safe cholecystectomy is a strategy directed
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to decrease this complication. It consists of six components. setting under general anesthesia with four-port technique. We
This study was done to evaluate and validate these components, excluded patients with body mass index >30 (as our rural hospital
modified and tailored to the setting of a rural hospital with emphasis was not equipped with facilities to operate on obese patients) and
on a bystander surgeon. patients with acute cholecystitis who presented beyond 72 hours of
symptom development from our study. We adopted components
MAterIAls And Methods of safe cholecystectomy tailored to our settings of a rural hospital
with emphasis on bystander surgeon as detailed below.
This was a prospective study conducted at District Hospital
Anantnag, a rural health care center located in the Indian valley of • Operating surgeon dissected Calot’s triangle and ensured that
Kashmir, from September 2016 to September 2018. Three-hundred critical view of safety (CVS) was achieved.
and eighty-two patients admitted for LC were enrolled. Clinical • Starting dissection from a fixed extra biliary point, i.e., Rouviere’s
history, physical examination, blood counts, biochemistry, and sulcus.
abdominal ultrasound were routine in all patients. Preanesthetic • Intraoperative time-out before transecting cystic duct and
check-up was done in all. The operations were done in elective artery.

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