Segment IV approach for difficult laparoscopic cholecystectomy

Abstract

Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D‐line) as a feasible landmark for carrying out difficult LC. The D‐line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D‐line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty‐two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D‐line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D‐line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54‐290) min and 10 (range, 0‐100) mL, respectively. No intra‐ or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.

The segment IV approach: a useful method for achieving the critical view of safety during laparoscopic cholecystectomy in patients with anomalous bile duct

“…As have been described in our original report, the anterior Glissonean pedicle across on the back side of the D-line which is easily identi ed by using exible laparoscope, and is secured by using of blunt-tip dissecting forceps. Also D-line lies apart more than 3mm from the roof of the Rouviére's sulcus regardless of the shape of caudal surface of the segment IV [6].…”

“…One explanation for this discrepancy could be the existence of anatomical variations such as the anomalous bile duct. It is universally accepted that in all biliary systems, including the anomalous bile duct converging to the hilar plate system [1,5,6,10], the risk of VBI can be decreased by avoiding dissection through the hilar plate. The concept of the CVS have been proposed to avoid misidenti cation of major vasculo-biliary components during LC [7].…”

“…The operating gauze, which is isolated along the D-line, acts as a constantly visible landmark to safe dissection. Based on our experience, the D-line corresponds to the narrow segment of the gallbladder neck, which facilitates the isolation of the gallbladder [6]. While the D-line corresponds to proximal root of the cystic plate, bile ducts are not exist on the side of the D-line.…”

“…The concept of the segment IV approach has been published elsewhere [6]. The anatomical variation of the biliary system in relation to the segment IV approach is illustrated in Fig.…”

“…Recently, we used the right posterior corner of the quadrate lobe of the liver, corresponding to the inferior surface of the segment IV, as a speci c point to start dissection of the gallbladder. The dissection of the gallbladder is securely performed along the diagonal line (D-line) of the quadrate lobe, represented by the imaginary line connecting the left ventral and right posterior corner of the quadrate lobe of the liver [6]. We named this the segment IV approach.…”