Abcd of lapchole

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

1. ABCD of Safe Lap Chole PROF. DR SREEJOY PATNAIK E.C MEMBER ASI , EX- ORGANISING SECY - ASICON & IAGES 2019, BHUBANESWAR SHANTI MEMORIAL SUPER SPECIALITY HOSPITAL CUTTACK ODISHA

2. Culture of safety in cholecystectomy, adopted by “ SAGES SAFE CHOLECYSTECTOMY PROGRAM” Minimize Bile Duct Injuries Educate surgeons and apprise them of basic tenets of safe performance of LC COSIC

3. INTRODUCTION Most commonly performed procedure worldwide. It is one of the more unpredictable operations in general Sx , due to variable operative findings. A safe cholecystectomy is one that is safe for both the patient and for the surgeon. ( Medico-legal) The incidence of biliary injury declining 2T in OC. Major BVI - significant morbidity. Recent data -BDI rates (0.32%-0.52%) without any significant change in the morbidity or mortality. Prevention is the best strategy.

4. The Pearls of wisdom for a safe Laparoscopic cholecystectomy: 1.Knowledge of surgical relevant anatomy 2.Factors predictive of difficult cholecystectomy. 3. Execution of Correct technique 4.Concept of “Time-Out”. 5.Judicious use of Energy devices. 6.Understanding CVS. 7.Remembrance of Error Traps 8.Understanding “stopping rules” 9.Use of Intraop . Imaging techniques 10.Bailout strategies 11. Documentation

5. 1.Knowledge of Surgical relevant anatomy: Vital structures (portal vein, hepatic artery and extrahepatic biliary tract). Common anatomical variations, and distortions due to pathological processes ( e.g ., acute/chronic cholecystitis). Safe execution -understanding of following anatomical terms/landmarks.

6. The Anatomical terms / Landmarks. Hepatocystic triangle Cystic plate Rouviere’s sulcus Umbilical fissure Segment 4 liver Anatomical Vascular variations Biliary ductal anomalies

7. Hepatocystic triangle This is an area on the under surface of the liver on the right side of the hepatic hilum. Boundaries: 1.CHD on the medial side 2.Cystic duct caudally. 3.Liver under surface cranially. Contents: ​ Cystic artery Variable portion of RHA Cystic lymph node Lymphatics Fibro-fatty connective tissue. Anatomy of hepatocystic and Calot’s triangles. A: Hepatocystic triangle (red outline); Calot’s triangle (in blue); Relevant anatomical structures; B: Before dissection; C: After dissection. CD: Cystic duct; CA: Cystic artery; LN: Lymph node; HAP: Hepatic artery proper; CBD: Common bile duct.

8. Clinical significance: This is the target area for dissection during LC. The cystic lymph node often lies superficial to the CA - landmark to locate this artery. The CA should be divided on the right side of this lymph node close to the gallbladder to avoid injury to the right hepatic artery. Difficult cases – inflammation + - thick, fibrotic, or scarred - difficulty in anatomical identification and/or dissection.

9. Cystic plate This is a flat ovoid fibrous sheet located in the gallbladder bed / a part of the liver. With GB in-situ, not visible as it is covered by it. It is continuous with liver capsule of segment and segment 5. Postero -medially at hepatic hilum, it narrows to become a stout cord like structure that is continuous with the sheath of the right portal pedicle It is exposed as whitish/greyish structure once the gallbladder is dissected off the liver. Cystic plate is visualized after the gallbladder is dissected off its liver bed.

10. Clinical significance: The lower 3 rd cystic plate needs to be exposed to achieve the CVS. Dissection should remain close to the GB wall while dissecting it off the liver bed. Incomplete exposure – injury to an anomalous duct ( e.g ., right posterior sectional duct). Inflammation – longitudinal length of CP leads to pathological shortening. Any Breach – 1.Troublesome bleeding from liver parenchyma, especially if the terminal tributaries of the middle hepatic vein. 2. Sub-vesical bile duct s (close to GB fossa) may be injured, causing a postoperative bile leak. Understanding surgical planes during dissection. A: Usually, in uncomplicated cases , plane of dissection remains close to the gallbladder that leaves behind the cystic plate attached to liver; B: In chronic cholecystitis , with small shrunken gallbladder, liver puckering develops (red curved arrow) with shortening of the cystic plate (black interrupted arrow). With loss of plane, the surgeon tends to breach the cystic plate (red arrows) resulting in bleeding from the liver. In addition, there is a risk to enter in to the right portal pedicle during fundus first approach (blue arrow) if such danger is not appreciated; C : Pucker sign as noted during open cholecystectomy; D: Small contracted scarred gallbladder (in white circle) was identified after separating adherent omentum and colon. Duodenum (Du) was densely adherent to the gallbladder. Findings such as in C and D suggest difficult cholecystectomy.

11. Rouviere’s sulcus : This sulcus is 2-5 cm long and is present on the under surface of the right lobe of the liver, running to the right of the hepatic hilum . Visible in (80%) cases, remains open (partly or fully) - contains right portal pedicle or its branches. Best visible -GB neck is retracted towards the umbilical fissure .

12. Clinical significance Fixed anatomical landmark . It indicates the plane of the CBD thus helps to reorient surgeon in cases of difficultly. All the dissection must be done cephalad to the ( R4U line)  . The fissure of Gans  is also known as  Rouvières sulcus or the incisura hepatis dextra . 

13. B-SAFE anatomical landmarks and R4U safety line. If Rouviere’s sulcus is not present. B-SAFE and R4U safety line - Safe  zones of dissection: B-SAFE: ( B ) Bile duct and base of segment 4 (S) Rouviere sulcus and segment 4 Hepatic artery (F) Umbilical fissure (E) Enteric viscera e.g., duodenum, pylorus . R4U safety line: ( LAKSHMAN REKHA) Is an imaginary line passing across the base of the segment 4 from the umbilical fissure extending right across the hepatoduodenal ligament . It ascertains safe zone of dissection. R- Rouviere sulcus 4- segment 4 U- Umbilical fissure

14. Sulcus acts as a fixed anatomical landmark during LC. Indicates the plane of the CBD thus helps to reorient surgeon in cases of difficultly. All the dissection must be done ventral and cephalad ( SAFE) to the line joining the roof of this sulcus and base of segment 4 ( R4U line) No dissection to be done below this line / landmark .(UNSAFE) Clinical Significance

15. Umbilical fissure: This is a fissure between the left lateral section (segments 2, 3) and left medial section (segment 4) where the falciform ligament and ligamentum teres lie. Clinical significance:  This also acts as a fixed anatomical landmark, and helps the operating surgeon to reorient in difficult situations.

16. Segment 4 This is the left medial section of the liver. Location - between the umbilical fissure and the gallbladder Segment 4 lies lateral to the falciform ligament and is subdivided into 4a (superior) and 4b (inferior) Segment 4 a & b

17. Anatomical variations : Vascular anomalies The cystic artery ( CA) and the right hepatic artery (RHA) 2 important vessels. The cystic artery is usually single (approx. 79%), originates from RHA. In 81.5% traverses the HCT to supply GB by 2 branches – Superf . & deep. Variations in its origin, number, or course. Pass anterior to the common hepatic/ bile duct (17.9%) Short (< 1 cm) cystic artery (9.5%) Multiple cystic arteries (8.9%) Located inferior to the cystic duct (4.9%)

18. Significance: Short Cystic Artery - RHA may be clipped and divided. Dissection close to the GB & Rt. side of the cystic lymph node. Cystic Artery may not be localised or -Low lying -- arising from GDA or LHA (doesn’t pass through HCT.) RHA:- pass behind the CHD (87%). Aberrant RHA(replaced or accessory): Courses behind the portal vein and CBD, comes to lie on the rt. side of the bile duct.

19. Clinical importance: Replaced RHA - large cystic artery - might be injured if not identified correctly. RHA may take a tortuous course ( Caterpillar turn/Moynihan’s hump ) a short CA. Caterpillar turn/Moynihan’s hump)

20. Biliary ductal anomalies : Cystic ductal variations, anatomical and pathological The CD - 2-4 cm long and 2-3 mm wide. Congenitally absent (very rare) / very long ( >5 cm ). Angular insertion- 75% Parallel -20% Spiral - 5% Enter the RHD - 0.6%-2.3% ( anomalous right sectional duct) Enter CHD quite low near the ampulla. An anomalous right sectional duct, especially a right posterior sectional duct, may join the biliary tree at a level lower than usual Duplication of the CBD. E: Short/effaced cystic duct due to impacted stone in the gallbladder neck A : Normal pattern with angular insertion B : Cystic duct insertion in aberrant right hepatic (sectional) duct C : Cystic duct - parallel course. Cystic duct may be quiet long and may join the common hepatic duct (CHD) near ampulla D: Cystic ductal fusion with the CHD due to inflammation In D and E, CHD would be at risk of injury – on exposing the CD –CBD junction.

21. Clinical importance: CYSTIC DUCT AND COMMON HEPATIC DUCT VARIATIONS: The length ,course & it’s joining pattern of the Cystic duct with CHD are variable. Inflammation - may be adherent and fused with parallel insertion . Shortened or effaced by the impacted stone ( Mirizzi”s Syndrome). The surgeon should be careful - may need to resort to one of the bail-out techniques.

22. 2. Factors Predictive of Difficult Cholecystectomy

23. Gallbladder is not visualized in both of these situations predicting difficult dissection. The surgeon should be careful during dissection as adjoining adherent viscera, duodenum or colon, might be injured during adhesiolysis . A Moderate pericholecystic adhesions Extensive pericholecystic adhesion. Examples of intraoperative prediction of difficult gallbladder .

24. A comprehensive scoring system, e.g ., CLOC score, may also be useful in clinical practice to predict conversion to open cholecystectomy. Low risk patients (CLOC score <6) are suitable for surgical registrars in the early phase of training. High risk patients (CLOC score > 6 ) should be operated by experienced surgeons. CLOC SCORING – LAP – OPEN

25. Nassar difficulty grading score

26. 3.EXECUTION OF CORRECT TECHNIQUE: The basic essential steps of LC include: GB retraction (to open up and expose HC triangle in preparation for next step), Dissection in the HC triangle to achieve the CVS. Clipping and division of the cystic duct and the cystic artery. Dissection of the GB from its bed Correct exposure/display of the HC triangle: FUNDAL AND INFUNDIBULAR RETRACTIONS - VERY IMPORTANT IN ACHIEVING CVS . Proper retraction opens up the HC triangle - Diamond shape ( Extended Biliary triangle) that gradually becomes more appreciable as the dissection proceeds till CVS is achieved .

27. Importance of proper retraction of gallbladder during laparoscopic cholecystectomy.

28. Proper retraction of infundibulum: A : Exposure of anterior aspect of hepatocystic (HC) triangle when infundibulum is retracted in right inferolateral direction B: Exposure of posterior aspect of HC triangle when infundibulum is retracted towards umbilical fissure. If the infundibulum is not retracted adequately in the correct direction, the CBD will be pulled towards the RUQ ,resulting in parallel alignment of the CD and the CBD In this situation the CBD may be mistaken for the CD.

29. Difficult scenarios: Useful manoeuvres Difficulty in grasping and retracting the fundus , the GB may be decompressed by aspiration, or a stay suture may be taken to facilitate retraction Impacted large stone in the Hartmann’s pouch -- dislodge before the GB can be grasped and retracted properly A firm liver, as in cirrhosis, - Retraction can be facilitated by taking stay sutures.

30. Safe zones of dissection Surgeon to know the safe zone of dissection to delineate the cystic duct and the cystic artery. Fixed anatomical landmark (B-SAFE) will help the surgeon to identify and remain in the safe zone of dissection. Surgical field of interest during laparoscopic cholecystectomy. It is important to identify safe (green) and danger (red) zones of dissection as demarcated by R4U line. B-SAFE anatomical landmarks and R4U safety line

31. 4 . Concept of “time-out”

32. Flowchart showing overall scheme of performance of laparoscopic cholecystectomy with the culture of safety concept. GB: Gallbladder; B-SAFE: Surgical landmarks; HC triangle: Hepatocystic triangle; CVS: Critical view of safety. TIME OUT 1 TIME OUT 2 TIME OUT 3

33. 5.Judicious use of energy sources Energy devices used to dissect the HCT and to separate the GB from its bed: Monopolar cautery Bipolar cautery Ultrasonic energy devices. All these energy sources are appropriate for safe LC. Awareness of safe handling of these energy devices. Monopolar hook important points: Keep it at low setting (≤ 30W) to avoid arcing of current to the bile duct. Divide a small amount of tissue at a time after a gentle pull to avoid injury to deeper structures by the heel of the hook cautery; Use intermittent short bursts of current at 2-3 s intervals avoid thermal spread to the bile duct. Avoid blind use of cautery in the case of brisk bleeding. Ultrasonic energy source. – best as considering its minimal lateral spread. Bipolar cautery is useful to control bleeding in the HC triangle and in the liver bed.

34. 6. Concept of the CVS The concept of the “CVS” was introduced in an attempt to decrease the misidentification injury of structures in the HCT. Its aim - conclusive identification of the cystic duct and the cystic artery (two targets) to avoid misidentification injury. The HCT dissection is done to achieve the Extended hepatobiliary triangle- lower boundary which is formed by the part of the GB along with the CD. upper boundary is also formed by the cystic plate along with the liver surface. This enhances the safety margin against misidentification of any aberrant structures, and also saves time during subsequent dissection after the cystic duct and the artery have been divided.

35. What is the CVS? DEFINITION : It is the final view that is achieved after a thorough dissection of the HCT to delineate the cystic duct and the cystic artery before they are clipped and divided. The CVS has 3 components and all must be met for achieving it. 1 .Clearance of the HC triangle: The HC triangle should be cleared of all the fibro- fatty and soft areolar tissue. The under surface of the liver is easily seen across this triangle. 2. Exposure of the lower cystic plate : The GB should be separated from its liver bed to expose at least the lower 3 rd of the cystic plate. 3. Two and only two tubular structures should be seen entering the gallbladder : the Cystic duct and the cystic artery.

36. Doublet view: CVS Anterior view Posterior view (inverted hepatocystic triangle). The CVS should be seen clearly both from front and the back to have complete circumferential visualization of cystic duct and artery (doublet view). The anterior view is easily visible by retracting the infundibulum infero -laterally towards right (with segment 5 surface visible across window) while the posterior view (inverted/reverse HC triangle) requires the infundibulum to be retracted towards the umbilical fissure (with segment 4/quadrate lobe surface visible across window) Complete circumferential visualization of cystic duct and artery (doublet view)

37. Clinical importance of the CVS Most effective method/ technique of preventing BDI as reported in many recent studies. Surgeons must incorporate it in routine practice. Understand the concept and use it correctly. Barrier - biliary- vascular injury. Method of target identification. Failure to achieve- higher risk of injury – continue dissection.

38. Important steps during laparoscopic cholecystectomy.

39. Lap Chole – steps

40. 7.Remembering error traps Apart from CVS, there are other techniques of target identification during LC 1.Infundibular techniques. 2.Fundus first technique. 3.Intraoperative cholangiogram. Surgeons using this technique should always be aware of this error trap . Fallacies : The deception of the hidden cystic duct and the CHD junction . Left: Appearance to surgeon when a duct appearing to be the cystic duct is dissected first. Right: True anatomic situation in the case of some classical injuries. The “flare” (heavy black line ) is from the separation of CD and CHD or its side & the side of the gallbladder. In the infundibular technique , cystic duct identification is based on the appearance of the infundibulum-cystic duct junction as a funnel. CBD may be misidentified as the cystic duct – This leads to classical BDI where the CBD is divided twice before the gallbladder could be completely separated from the liv er.

41. In the) the GB fundus is dissected first off its liver bed/cystic plate, lastly the CD and the artery are divided. Another error trap for the surgeon - local anatomy of the cystic plate not well appreciated. GB tends to twist once separately completely from the liver - technical challenge of handling. Difficult Retraction of liver. - small shrunken fused GB. Pathological shortening of the CP ( Puckering) - Breach in CP -right portal pedicle or hilar injuries. With loss of plane, breaching the cystic plate (red arrows) Fundus first technique ( dome-down technique)

42. 8. Understand “Stopping rules.” The surgeon should recognize these clues, stop the dissection, and then to decide the strategy for a safe operation before the dissection starts again ( use “time-out ”).

43. Call for help/second opinion / Assistance It is advisable that operating surgeon should take a pause and seek a 2 nd opinion from another surgeon in event of any- unexpected finding difficult GB, unusual anatomy difficult dissection. Misidentification is the major cause of biliary/vascular injury : CBD/CHD is misidentified as the cystic duct – (65%) Hepatic artery is misidentified as the cystic artery (10%). Can be prevented with the advice from a 2 nd surgeon -18% . It should be considered as a sign of good clinical practice rather than a sign of surgical ineptitude.

44. Techniques of intraop . assessment of biliary anatomy that may result in decreased incidence of BDI.. Intraoperative cholangiography (IOC): It is the most commonly performed. Identification and assessment of extent of biliary injury, and possible prevention of BDI . It is a safe technique 90%–95% success rate. Detects asymptomatic CBD stones. Pitfalls: Ductal cannulation can be difficult in patients with short and thin cystic ducts. Adds to the operative time and cost High learning curve involved for correct interpretation. There is need for radiographic equipment. 9.Use of intraoperative imaging

45. Laparoscopic ultrasound : LUS Many outcome studies support LUS for prevention of BDI. Non-invasive. Shorter procedure time Higher success rates Lack of radiation exposure. Pitfalls: Less accurate for the assessment of the intrapancreatic and intrahepatic parts of the biliary system. Long learning curve. Near infrared fluorescent ICG cholangiography : NIRFC is the most recent addition to the armamentarium for intraop . assessment of biliary tract. Its efficacy and safety have been confirmed in various studies. takes less time cheaper and safer. new technique, its use in various biliary pathologies has not yet been evaluated .

46. ICG LAP CHOLECYSTECTOMY VIDEO

47. 10.Bailout strategies Bail out techniques - alternate procedures that allows the surgeon to complete the procedure in a safe manner. ( i.e ., safety first). in a difficult situation. The goal is not not to go ahead and complete the procedure - & risking patient safety due to potential of BVI injury. Follow the 5 bailout strategies in difficult situations : Abort the procedure altogether Convert to an open procedure Tube cholecystostomy Subtotal cholecystectomy (STC, open/lap) Fundus first cholecystectomy The best choice will depend on the clinical judgement and the experience/expertise of the surgeon.

48. Laparoscopic subtotal cholecystectomy - bailout procedure. A: Mucosa of the gallbladder stump is fulgurated after removal of as much gallbladder as safely possible B: Stump is closed after ensuring no stone is left behind in this stump . 2 types of STC - kept closed or is left open. This stump may vary in length and part of the GB wall may be left attached to the liver in both types. STC - the stump is closed, either with sutures or with staples. Subtotal fenestrating cholecystectomy - the stump is left open, with or without closing the cystic duct opening.

49. Empyma GB , impacted stone

50. 11.DOCUMENTATION Since malpractice claim in GI Surgery is most common – one should strictly adhere to meticulous documentation. As Literature is scant, OT notes reflect what was actually performed during the operation. Vigilant - writing OT notes. Inadequate documentation - “error-trap” as 20%-30% of lap. biliary injury - malpractice litigation. All descriptions of the measures taken (e.g., achieving CVS) + photo/video should be documented. STC performed – mention type and the size of gallbladder stump - for future reference - recurrent stones in the stump.

51. Advise to every surgeon & team involved in LC should be aware of the concept of “COSIC”. Should be routinely adopted & practiced in each & every case. Always remember the 11 points which I mentioned CONCLUSION :