Ten‐year Audit of Safe Bail‐Out Alternatives to the Critical View of Safety in Laparoscopic Cholecystectomy

Abstract

Background To prevent vasculobiliary injuries according to the Tokyo Guidelines, Critical View of Safety (CVS) is the recommended method for the identification of the cystic duct and cystic artery. Our aim was to audit laparoscopic cholecystectomies, in order to determine the rate of CVS feasibility and to explore safe bail‐out alternatives, when CVS cannot be obtained. Methods Patients who underwent either elective or emergent laparoscopic cholecystectomy, between January 2009 and December 2018, in whom the CVS was attempted, were retrospectively identified from the institutional electronic database. Dissection technique was documented in the operative notes. Bile duct injuries (BDI) were classified by the Strasberg classification, and their management and outcome were reported in the patient files. Results In total, 1226 cases were included in the final analysis. CVS was feasible in 1128 cases (92.0%), whereas 65 patients (5.3%) were managed laparoscopically by a bail‐out technique. Of those, 52 (4.3%) underwent a subtotal cholecystectomy, 12 (0.9%) a fundus‐first cholecystectomy, and in one patient (0.1%) the operation was concluded by a tube cholecystostomy. Overall conversion rate was 2.7% (33/1226 cases). Male gender, older age, junior surgeons, and acute cholecystitis were significantly associated with higher conversion rates. Post‐operatively, 10 patients (0.82%) developed a type A bile leakage. No major BDI (types B–E) were observed, either with CVS or the bail‐out techniques. Conclusions Our study showed that CVS and the bail‐out alternatives complement each other in preventing major BDI and should belong to the armamentarium of every modern surgeon.

Navigation with laparoscopic ultrasound during fundus-first laparoscopic cholecystectomy-a single-centre retrospective case control study

“…CVS is not a dissection technique, but rather a technique of identi cation similar to the safety measures during hunting or ying [13,15]. There is no need to expose the common bile or hepatic duct while obtaining CVS [2]. CVS usually protects against incorrect identi cation but not against BDI and VBI during dissection when the local conditions are changed [15].…”

“…CVS usually protects against incorrect identi cation but not against BDI and VBI during dissection when the local conditions are changed [15]. The possible bail-out techniques when CVS can not be reached include FF LC, subtotal LC, tube cholecystostomy or conversion [2,16].…”

“…During FF LC the gallbladder is dissected off the liver bed beginning with the fundus towards the infundibulum until it is hanging on the cystic duct and the cystic artery or it may be combined with the subtotal cholecystectomy [2]. The preferred dissection technique should be between the subserosal outer and inner layer of the gallbladder wall but in case of in ammation it may be very di cult [6].…”

“…The preferred dissection technique should be between the subserosal outer and inner layer of the gallbladder wall but in case of in ammation it may be very di cult [6]. The complications may involve haemorrhage from the liver bed or the gallbladder wall, migration of stones into the common bile duct or BDI/VBI associated with improper plane of dissection and higher rate of perforation of the gallbladder wall thus a stepby-step preparation and proper hemostasis are advised [2,3,5]. During standard technique the grasper on the fundus of the gallbladder is used to apply traction to expose the triangle of Calot [4].…”

“…Fundus-rst (FF) laparoscopic cholecystectomy (LC) is a technique which is used by some surgeons as a standard LC technique or, more often, as a bail-out procedure in case of a di cult LC [1][2][3][4][5]. Bile duct injury (BDI) or vasculobiliary injury (VBI) may be associated with the chronic in ammation in the region of Calot's triangle and di culties to de ne the safe plane of dissection during FF technique [2]. There are several visual landmarks like the Rouvier's sulcus, the base of liver segment IV or the sentinel node which may help to avoid BDI or VBI, but during preparation and in ammation the anatomical conditions are usually changed [6].…”