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Anatomy relevant to cholecystectomy
Abstract
This review discusses anatomical facts that are of relevance to the performance of a safe cholecystectomy. Misinterpretation of normal anatomy and anatomical variations contribute to the occurrence of major postoperative complications like biliary injuries following a cholecystectomy, the incidence being higher with laparoscopic cholecystectomy. A look at the basic anatomy is therefore important for biliary and minimally invasive surgeons. This includes normal anatomy and variations of the biliary apparatus as well as the arterial supply to the gallbladder. Specific anatomical distortions due to the laparoscopic technique, their contribution in producing injury and a preventive strategy based on this understanding are discussed. Investigative modalities that may help in assessing anatomy are considered. Newer insights into the role of anatomic illusions as well as the role of a system-based approach to preventing injuries is also discussed.
... In an comprehensive review on the anatomy relevant to cholecystectomy, Nagral stated that not only is it common to misinterpret the normal anatomy of the CA, it is equally common to come across anatomical variations in its origin and course that can predispose to an increased incidence of arterial and biliary injuries during a cholecystectomy procedure [7]. He mentioned that the RHA usually courses behind the CBD to enter the triangle and then gives off the CA within the triangle. ...
... He also mentioned that the CA may give off branches to the CD during its course through the triangle. These must be divided appropriately to visualize the complete length of the CD [7]. In the present study in one cadaver, the CA traversed very high in the triangle along its upper border. ...
... Chamberlain, Aristotle, Abeysuriya et al. as well as U Dandekar and K Dandekar have reported similar findings with incidences of 10%, 5% and 26.8% respectively [11][12][13][14]. Nagral mentioned that usually CA's which originate from sources other than the RHA, tend to pass anteriorly to ductal structures and are thus more prone to injury [7]. In present study, however, out of the 5 cadavers in which the CA passed anterior to the CHD, in four of the cases the CA originated from the RHA and in one cadaver the CA was found originating from the CHA. ...
... Dissection in the hepatocystic triangle is performed to obtain the 'critical view of safety'. Misidentifying the normal anatomy and failing to recognize anatomical variants of significance can lead to surgical complications [12]. It is imperative to ensure that only two structures enter the gallbladder: the cystic duct and the cystic artery [3,12]. ...
... Misidentifying the normal anatomy and failing to recognize anatomical variants of significance can lead to surgical complications [12]. It is imperative to ensure that only two structures enter the gallbladder: the cystic duct and the cystic artery [3,12]. The cystic artery and the cystic duct are ligated, and then the gallbladder is removed [3]. ...
... Intraoperative cholangiogram may be routinely performed by some surgeons [3]. Others may use it as a problem-solving tool if biliary anatomy is uncertain or there is suspicion of biliary injury or for evaluating possible choledocholithiasis [3,12]. ...
Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.
Graphical abstract
... Much variation was found about the length and diameter of the cystic duct by different workers 1,2,3,4,5,6,7 . Most of the workers mentioned that the cystic duct usually 3-4 cm in length but Sanjay (2005) 5 stated that around 20% of cystic duct are less than 2 cm in length and the cystic duct frequently exhibits a tortuous or serpentine course. ...
... Much variation was found about the length and diameter of the cystic duct by different workers 1,2,3,4,5,6,7 . Most of the workers mentioned that the cystic duct usually 3-4 cm in length but Sanjay (2005) 5 stated that around 20% of cystic duct are less than 2 cm in length and the cystic duct frequently exhibits a tortuous or serpentine course. Hence there may be very little space to put clips or ligatures during cholecystectomy. ...
... Much variation was found about the length and diameter of the cystic duct by different workers 1,2,3,4,5,6,7 . Most of the workers mentioned that the cystic duct usually 3-4 cm in length but Sanjay (2005) 5 stated that around 20% of cystic duct are less than 2 cm in length and the cystic duct frequently exhibits a tortuous or serpentine course. Hence there may be very little space to put clips or ligatures during cholecystectomy. ...
Background: An increasing incidence of liver and gall bladder diseases bring about an increasing necessity of their precise diagnosis. Unrecognized anatomic variants of the extrahepatic billiary apparatus may cause confusion on imaging studies and complicate subsequent surgical, endoscopic, and percutaneous procedures. Although much have been written about the normal anatomy and related diseases of the gallbladder and biliary tract but no available data have been found about the variations of the cystic duct in Bangladeshi people. This study was aimed at determining the anatomical variations of gross morphological features of cystic duct in relation to age and sex in Bangladeshi people as well as to find out any congenital anomalies of the extrahepatic biliary system. Materials and methods: A cross sectional descriptive type of study was carried out at the Department of Anatomy, Rangpur Medical College, Rangpur. The study was conducted on postmortem gallbladder with cystic duct from 60 unclaimed dead bodies of Bangladeshi people. Of which, 32 were male specimens and 28 were female specimens. The specimens were divided into two groups according to age, young age group A (20-40 years) and elderly age group B (41-65 years). The length and diameter of cystic duct was measured and number of valves in cystic duct was counted. Comparison was done between male and female of two age groups by Student’s unpaired‘t’ test. Results: The length of the cystic duct showed a significantly higher value in elderly male than younger male and corresponding f emale groups of similar age. The number of spiral valves showed similar values in both sexes. Conclusion: No relationship between cystic duct length, diameter and number of spiral valves with different sex and different age could be established in this study. Bangladesh Journal of Anatomy July 2015, Vol. 13, No. 2, pp. 32-36
... Calot also mentioned in his dissertation that the triangle is bounded inferiorly by the cystic duct, medially by the common hepatic duct (CHD), and superiorly by the cystic artery (CA), with a distance of 3-4 mm from the right hepatic artery (RHA) in a third of the cases [11]. The modern surgical definition differs from the original in that the triangle is bounded superiorly by the inferior surface of the liver, inferiorly by the cystic duct, and medially by the CHD [30] (Fig. 1). ...
... The hepatic component refers to underside of the liver, replacing the CA as the upper boundary of this space. The main contents are RHA, CA, lymphatic vessels, and connective tissue [30]. The CA begins as a branch of the RHA within the hepatocystic triangle and runs just cranial to the cystic duct towards the gallbladder, where it divides into superficial and deep branches; the deep branch runs between the liver and the gallbladder itself. ...
... RHA is the branch of hepatic artery proper which is continuation of common hepatic artery (CHA) but, may take origin from various anatomical locations, including the aorta and superior mesenteric artery. CHA often follows the path of the common bile duct (CBD) and then connects the right stalk to the liver at the apex of the CT [5,30]. Moynihan's hump is an extremely unusual configuration (forming a U-shaped loop, or S-shaped or tortuous or meandering course) in which the right hepatic artery passes very close to the gallbladder and cystic duct. ...
A rare variation known as “Moynihan’s or caterpillar hump” of the right hepatic artery raises the danger of vascular and biliary injuries during hepatobiliary surgery. This research intends to carefully record every case (i.e., patients undergoing laparoscopic cholecystectomy or cadaver dissections) where the right hepatic artery received a caterpillar hump.
Methods
The literature search was conducted with the medical subject headings (MeSH) and EMTREE (subject headings unique to Embase) keywords. The keywords with Boolean operators (OR, AND, and NOT) were used to create search strings in all possible combinations to retrieve bibliographic data. Two authors independently performed a risk of bias assessment and data extraction. The random effects model was used to conduct a meta-analysis.
Results
Thirty studies with a total of 8418 subjects reported that Moynihan's hump was present in 3.81% of them, with a predictive interval of 0.88–16.45%. The incidence of the hump was 3.1% in surgical studies (7496 subjects) and 7.22% (95% CI 4.7–10.93%) in cadaveric data (625 cadavers). Only ten studies addressed the relationship between the caterpillar hump and the common bile duct.
Conclusion
A patient with an unusually “small cystic artery” or “large right hepatic artery” is likely to have a “caterpillar hump”. The caterpillar’s hump of the right hepatic artery is subject to rare anatomical variations in its course that increase the risk of incorrect vessel ligation or injury during laparoscopic cholecystectomy.
... In order to develop new surgical techniques for gallbladder removing, the domestic swine is widely used as one of the most suitable experimental models for cholecystectomy [18]. Misinterpretation or lack of knowledge of this information contributes to intraoperative complications such as biliary injuries, which can cause serious morbidity and occasionally mortality [9]. Information about the presence of such triangles in animals was not found. ...
... Later, Calot`s space was renamed as to hepatobiliary, hepatocystic or cystohepatic triangle; with a superior border given by the visceral surface of the liver, medial border -by the common hepatic duct and inferior border -by the cystic duct draining the gallbladder [6]. Therefore, the modern triangle appears to provide the surgeon with a more constant triangle boundary, one that would otherwise be variable, given the occasionally inconsistent pattern of the cystic artery [9]. The contents of cystohepatic triangle include the right hepatic arteria, cystic artery, lymph node of gallbladder, lymphatics and fibro-fatty connective tissue areа. ...
... Laparoscopic surgery is a technique often chosen in case of gallbladder stones [9]. Vascular and ductal variations can disorientate the surgeon during performing of laparoscopic technic [1]. ...
... Vital structures including major vessels and organs are densely positioned, and mistakes during the procedure can lead to lethal hemorrhage or damage to adjacent major organs. Therefore, thorough knowledge of the adjacent anatomical structure is imperative for safe lesion dissection (6)(7)(8)(9). In this review, we will discuss the surgical approach of each procedure, focusing on the related anatomy for safe operation. ...
... The blood supply to the gall bladder and cystic duct is from the cystic artery, which commonly stems from the right hepatic artery in Calot's triangle. However, variations in the origin and course of the cystic artery occur in approximately 20% of patients (11), and a double cystic artery has been reported in 15% of patients (9). The cystic artery typically runs superior to the cystic duct and posterior to the common hepatic duct. ...
... The cystic duct connects the gallbladder to the common hepatic duct to form the common bile duct and is inarguably one of the most important structures to identify during cholecystectomy. The size of the cystic duct varies from 1 to 5 cm in length and from 3 to 7 mm in width; an exceptionally short (<2 cm) cystic duct may be a challenge due to the possible risk of damage to the biliary system (9). ...
As ovarian cancer commonly involves the visceral organs without boundary, more aggressive procedures are adopted during cytoreductive surgery. One of the most difficult aspect of the operation involves the procedure for the gall bladder, porta hepatis, and omental bursa. As the upper abdominal surgical field is not familiar to the gynecologic surgeon, and the vital organs or vessels are densely positioned, these procedures can be challenging for achieving the optimal cytoreductive surgery. The surgical approaches for advanced ovarian cancer that are required in the upper abdomen have evolved with the progress in surgical techniques. This article will discuss the surgical approach by focusing on cholecystectomy, porta hepatis debulking, and omental bursectomy, as well as the regional anatomy in patients with advanced ovarian cancer.
... Fundamentally, this triangle is bounded superiorly by the inferior border of the liver, inferiorly by the cystic duct, and medially by the common hepatic duct ( Figure 1). Its contents include the cystic artery, a variable portion of the right hepatic artery, the cystic lymph node and lymphatic vessels, as well as fibrous-adipose connective tissue 1,13,20 . ...
BACKGROUND: Knowledge of the cystic artery and its variations is essential to perform safe cholecystectomies. The cystic artery originates from the right hepatic artery, passing posterior to the common hepatic duct, anterior to the cystic duct, and branching into two branches at the neck of the gallbladder. However, variations in position, size, and relationship with adjacent structures are common.
AIMS: This article presents a literature review regarding cystic artery variations and their frequency during cholecystectomies.
METHODS: The articles selected for this review were chosen from the PubMed and SciELO databases. The standardized descriptors used were anatomic variation and cholecystectomy. These were chosen using the “Medical Subject Headings” and combined with the Boolean operator AND and the non-standard descriptor cystic artery.
RESULTS: It was found in 54.5% of the studies that the anatomical pattern of the cystic artery was the most frequent type. A different origin from the standard was cited in 63.6% of the articles. Double irrigation of the gallbladder was found in 59.1%. In 36.4%, the cystic artery was anterior to the common hepatic duct or the cystic duct. Cystic arteries outside Calot’s triangle were found in 36.4%. Short cystic arteries were found in 13.6%. The absence or non-identification of the artery was reported in 9.1%.
CONCLUSIONS: Variations of the cystic artery are common and are frequently reported. One aspect of a safe cholecystectomy is anatomical knowledge and its possible variations. Thus, surgeons must be familiar with this point in order to reduce vascular and biliary injuries.
HEADINGS:
Anatomy; Cholecystectomy; Anatomic Variation; Hepatic Artery
... Clinical practice, especially hepatobiliary surgery, stands to gain valuable insights from the study's classification and analysis of these variances. In addition, by helping doctors better grasp anatomy, the results will improve surgical outcomes and reduce iatrogenic problems [10,11] . ...
... Surgical skills depend on the surgeon's knowledge of relevant anatomy. 11,12 Factors such as age, male sex, obesity, comorbidities, ASA score, anatomical variations, previous surgeries, and pathologies can influence the difficulty of laparoscopic cholecystectomy. Intra-operative findings like gall bladder appearance, distension, access to the peritoneal cavity, local complications, and time taken in dissection of Calot's triangle indicate difficulty. ...
To assess clinical and radiological factors that predict difficult laparoscopic cholecystectomy.
Laparoscopic cholecystectomy is a complex surgical procedure involving anatomical variations, adhesions, and gall bladder contracting. Preoperative assessment is crucial for identifying risks and improving post-operative outcomes. The study identifies clinico-radiological factors predicting difficult laparoscopic cholecystectomy, improving preoperative planning, reducing conversion rates, and optimizing surgical preparedness and patient counseling for safer, more efficient practices.
A prospective observational study was conducted at the Department of General Surgery, Integral Institute of Medical Sciences and Research in Lucknow, involving 90 patients selected for Elective Laparoscopic Cholecystectomy and those with ultrasonographic ally proven cholelithiasis, excluding those with significant co-morbid illnesses or not fit for pneumoperitoneum creation. The study utilized IBM SPSS Stats 25.0 software for data analysis, presenting continuous data as mean±standard deviation and categorical/qualitative data as numbers and percentages.
Total 90 patients aged 15-70, with a majority female (77.8%), and a mean BMI of 18.5-30.0 kg/m2, with 48 patients under 25 kg/m2. A pre-operative scoring system for difficult laparoscopic cholecystectomy was developed using demographic, clinical, laboratory, and USG findings. The system ranged from 0-5 to 11-15 difficult surgeries, with a mean predictive score of 0-7. Most surgeries were predicted as easy, followed by difficult (18.9%) and very difficult (5.6%). Factors like age, BMI, hospitalization history, comorbidities, and abdominal scars were associated with ease of surgery.
The study assessed 90 patients aged 15-70 for difficult laparoscopic cholecystectomy procedures using a difficulty predicting scoring system, identifying factors like age, sex, hospitalization history, and BMI.
... Finally, in the presence of complex cases in which we are faced with severe adhesions or frozen triangles, a call for help or a diagnostic certainty tool, such as a diagnostic cholangiography must be kept in mind. (10) Remember that patient safety comes first . ...
We report the occurrence of a rare case of an anomaly in HPB tree- Moynihan's hump in NAMO MERI and SVBCH Hospital, Silvassa, India. Our patient was a middle aged woman, who presented with pain in abdomen since 5 months in our outpatient department. The data were documented through history, clinical examination, ultrasound examination and intra operative findings. The case was found to be a rare anomaly- Moynihan's hump. This case report emphasizes the attrition and the variation of normal human anatomy. Although the condition is extremely rare, it is a potential danger in its massive form, if timely diagnosis and management not done. Intra operative awareness of structural anatomy is a must before proceeding for such a case.
... We used the two benchmark publications by Michels [9,10] as a glossary of anatomy to clarify and establish a terminology of the anatomic elements relevant to the procedure of cholecystectomy under the dictum of the CVS. We reviewed the SAGES manual for safe cholecystectomy [58], the published anatomical studies in laparoscopic cholecystectomy [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37], review articles [38][39][40][41][42][43][44][45][46], studies in cadavers [12][13][14][15][16][17][18][19][20][21], angiographic imaging studies [47][48][49][50][51] and open cholecystectomy studies [52,60] to sum up the anatomical terms of the structures, the frequency of their occurrence, the rational of their grouping described in each publication. We discerned the "norm", the "variations", and their subcategories according to Kachlik et al. [62]. ...
Background and objectives: Laparoscopic cholecystectomy (LC) is the most commonly performed operation in general surgery in the Western World. Gallbladder surgery, although most of the time simple, always offers the possibility of unpleasant surprises. Despite progress, the incidence of common bile duct injury is 0.2–0.4%, causing devastating implications for the patient and the surgeon. This is mainly due to the failure to identify the normal anatomy properly. The literature review reveals a lack of structured knowledge in the surgical anatomy of cholecystectomy. The aim of this study was to develop a framework with a common anatomical language for safe laparoscopic and open cholecystectomy. Materials and Methods: The Hellenic Task Force group on the typology for Safe Laparoscopic Cholecystectomy performed a critical review of the literature on the laparoscopic anatomy of cholecystectomy. The results were compared with those of a clinical study of 279 patients undergoing LC for uncomplicated symptomatic gallstone disease. Results: Fourteen elements encountered during LC under the critical view of safety (CVS) approach were determined. The typical vascular–biliary pedicle with one cystic duct distributed laterally (or caudally) and one cystic artery medially (or cranially) lying at any point of the hepatocystic space was found in 66% of the cases studied. Anatomical schemata were formulated corresponding to the norm and four variations. Conclusions: The proposed cognitive anatomical schemata summarize simply what one can expect in terms of deviation from the norm. We believe that the synergy between the correct application of the CVS and the structured knowledge of the surgical anatomy in cholecystectomy helps the surgeon to handle non-typical structures safely and to complete the laparoscopic or open cholecystectomy without vascular–biliary injuries.
... It has significant role in reducing postoperative complications. As most of the complications associated with misidentification and misrecognition of the anatomy especially in biliary surgery [1][2][3][4][5]. ...
Scientific background: Laparoscopic cholecystectomy is the gold standard for surgical treatment of gallstones disease. Method: The study aimed to determine presence and types of Rouviere’s sulcus along with its association with gender, and postoperative morbidity among Sudanese patients presented for laparoscopic cholecystectomy, and operated on at Wad Madani Teaching Hospital, Gezira State, Sudan; during the period from November 2022 to November 2023. It was a comparative cross-sectional study. Study population were patients of more than 18 years old; where total coverage of them (150) was done. Data was collected from files and records of patients presented there during study period. Master sheet was used for data collection. SPSS version 25.0 was used for analysis. P-value ≤ 0.05 was considered significant. Results: Age of participants ranged from 17 to 85 years, with a mean age of 47.57 (SD ± 15.14). Majority of them were female (93.3%). Gallstones were present in 99.3%. Rouviere’s sulcus was identified intraoperatively among 92.7%. Identified sulcus type was: Open sulcus (54.0%), Close sulcus (27.3%), and Scar sulcus (11.3%). Postoperative operative outcomes: 95.3% experienced uneventful outcomes; and 4.7% experienced complications. Both postoperative complications and gender, had no statistical associations with the presence of Rouviere’s sulcus; P-value = 0.470, and 0.112 respectively. Also, there was no significant statistical association between gender and sulcus type (P-value 0.301). Conclusion and recommendations: No significant statistical association between both postoperative complications and gender with the presence of Rouviere’s sulcus, or between gender and sulcus type; was identified. Further study was highly recommended.
... Sometimes, one such vessels persist as the aberrant vessels at the sphere of the norm. 7 A rare variation was also seen by Dolensek J where an accessory left hepatic artery and accessory right hepatic artery from which double cystic artery arose (one of which was low lying). 8 My presented case is like this one. ...
During the laparoscopic cholecystectomy, a rare variation was found in a female patient. There was a large vessel exiting from liver parenchyma to gall bladder directly. It was pulsating; so was an unusual artery. The cystic artery was present properly at its usual anatomical site in Callot's triangle. The knowledge of these vascular variations is very significant in surgical interventions involving the biliary tree. It is of key importance for laparoscopic surgeons to know like this vascular variation to avoid catastrophic bleeding.The report emphasizes the vascular variation and the anomalous vessel to accomplish safe and uneventful hepatobiliary surgeri
... As a result, a thorough understanding of the anatomical features of the Calot's (hepatocystic) triangle under laparoscopic visual representation in addition to conventional cholecystectomy might be required again for secure implementation of whatever intervention. The mischaracterization of anatomical structures, along with the appearance of anatomical changes, have long been identified as contributing factors towards the occurrence of significant postoperative pain, especially biliary contusions, in the frame of reference of a cholecystectomy [9,10]. In turn, of that kind injuries can cause serious complications as well as, in rare instances, dying. ...
Introduction: The hepatocellular is made up of the gallbladder and liver. They are provided either by the coeliac trunk, which is one of the abdomen aorta's ventrolateral divisions. These hepatocellular frameworks are genuinely provided by sections of the hepatic aorta perfect, a branch of the posterior portion of the widely accepted hepatic artery that delivers components of the stomach, duodenum, as well as bottom portion of the bile duct via its gastro duodenal branch, whereas the proper hepatic artery delivers the right gastric artery but instead splits into right and left sections that deliver the right and left liver lobes. The gallbladder is supplied by a cystic subsidiary of the correct hepatic artery that travels across Calot's triangle. The mischaracterization of anatomical structures, along with the appearance of anatomical changes, have long been identified as contributing factors towards the occurrence of significant postoperative pain, especially biliary contusions, in the frame of reference of a cholecystectomy. Aims and Objectives: To characterize the course of the cystic artery concerning Calot's Triangle. Method: This current study considered 35 specimens of gallbladders from the well preserved bodies of Indian individuals. These individuals ranged from 30 years to 90 years during the time of their death. Samples of gallbladders with intact cystic ducts were considered from bodies during their examination in the Department of Anatomy. The samples were obtained with in 36 hours after death to ensure considerable study conditions. The dissection was done carefully and the course of the cystic artery was observed and noted down, especially concerning the position of Calot's Triangle. Result: The study found that 97.1% of the specimens showed that Calot's Triangle contains the cystic artery. The study also found that there were 32 specimens which showed cystic artery crossing over the Common Hepatic Duct (CHD) and 2 specimens where cystic artery crossed behind the CHD. Conclusion: The study concluded that more than 85% of its length, the cystic artery can be within Calot's Triangle and on average, 75% of its length crossed behind the CHD.
... The existence of an anatomical variation of the extrahepatic biliary ducts is a well-documented cause of biliary duct injury during laparoscopic cholecystectomy [29]. There are many anatomical [30], radiological [31] or intraoperative [29] description of hepato-cystic ducts. Their low frequency, estimated to range from 1 to 2% can explain the poor knowledge of these anatomical variations. ...
Gallstone is rare in children; however, sickle cell disease is associated with an increased risk of gallstone formation. We aimed to report particularity of diagnosis and management of gallstones in sickle cell children. We conducted a cross-sectional multicentric study in four hospitals of Dakar, in Senegal, during 18 years. We studied frequency, diagnostic particularities, management, and outcome. Among the 105 pediatric patients managed for gallstones, 87 (82.85%) had sickle cell disease. Among the latter, 18 (17.14%) were asymptomatic. Laparoscopic cholecystectomy was performed in 71 patients (67.62%). Following surgery, sickle cell patients were systematically hospitalized in the intensive care unit for 24 hours. Complications occurred in 7.6% and mortality in 1.9%. Gallstone is frequent in sickle cell children. Its management has good outcomes when taking in account particularities of these patients.
... A pathological part of gallbladder is known as the hartmann's pouch which is an outpouching of the neck of the gallbladder due to gallstones. The cystic duct is about 2-4 cm long and 1-3 mm wide; it is <2 cm in length in 20% of individuals [43]. The mucosa of cystic duct is spirally folded to form the valves of heister. ...
Gallstone disease (GSD) refers to all patients with symptoms due to gallstones (cholelithiasis). The presence of gallstones is a common problem seen in 10-15% of the Western population; with 1-4% developing symptoms. The most common presentation of patients with GSD is biliary colic. There are several mechanisms for cholelithiasis and all these processes are slow. Cholesterol stones are the most common variety of gallstones. Cholesterol stones cannot form if the gallbladder is completely emptied several times a day. Therefore, the total or partial extension of bile storage due to impaired gallbladder movement seems to be an important factor for cholelithiasis. Gallbladder dysmotility is an important risk factor for the development of GSD. Insufficient gallbladder motility may be associated with many risk factors for cholesterol gallstone formation, such as pregnant women, obese patients, and rapid weight loss, diabetes mellitus, and patients receiving total parenteral nutrition. Transabdominal ultrasound is the mainstay in the evaluation of patients with GSD. The presence of gallbladder dysfunction can be studied using cholecystokinin (CCK)-stimulated cholescintigraphy to evaluate for gallbladder ejection fraction (GBEF); with values <40% after 30 mins of CCK infusion considered diagnostic. The definitive treatment of GSD is cholecystectomy.
... This was perhaps due to a lack of knowledge of the 'laparoscopic anatomy', two dimensional 'laparoscopic view' and the dissection with long instruments without tactile feedback [29,32]. Misinterpretation of normal anatomy and anatomical variations contributed to major postoperative complications [33]. Conventional textbook description of the regional blood supply did not seem adequate in laparoscopic view [34]. ...
Background:Ligation of cystic artery is important surgical step involving gallbladder and hepatobiliary surgery. Right hepatic artery may come very close to gallbladder & cystic duct and CHD in the form of Caterpillar hump or Moynihan hump. Such hump has variations in position and depending on hump type, cystic artery anatomy is defined. In this situation right hepatic artery is liable to be mistakenly identified as cystic artery and it will be ligated prior to Cholecystectomy leading to right functional lobe of liver goes for necrosis. By defining types, increasing surgeon’s awareness, surgical complications will be reduced.
... In the state of New York after decades of operating laparoscopic cholecystectomies, Halbert publishes in 2017 the first paper to report that biliary complications could be reduced to values similar to those reported with the use of the open approach if sufficient and structured training is provided (4). Further more because of the high incidence of anatomical variations of the cystic artery and bile ducts associated with oedema of the tissues in acute inflammatory conditions, early laparoscopic cholecystectomy for acute cholecystitis is associated with higher risk of morbidity and thus not recommended in many regions of the Globe (7). ...
Introduction. Rapid developments in medical technology have allowed the incorporation of Indocyanine green (ICG) fluorescent cholangyography in the surgical technique armamentarium. The visualization of the biliary anatomy with augmented reality devices during surgery reduces complications and offer the perspective of challenging the safety paradigms which prohibited surgery in certain acute biliary conditions. Materials and methods. 43 consecutive patients were enrolled in a prospective interventional study and randomly divided into a cohort of 19 patients who had ICG injected prior to laparoscopic cholecystectomy and a cohort of 23 patients who received no fluorescent dye prior to surgery. In the ICG lot a Near Infrared Fluorescent System was used for the acquisition of fluorescent data in order to produce real time augmented reality imaging (ICG fluorescent cholangiography). The surgical technique and the indications for surgery were the same for the same in both cohorts of patients. Results and discussion. The cohort of patients receiving ICG had no complications and the mean operating time was 10 minutes less. The biliary anatomy was identified immediately in the ICG cohort with a specificity of 89.4% for the common bule duct and 73.6% for the cystic duct. In the non ICG cohort 21% of the CBDs and 43.4% of the cystic ducts were identified with difficulty during the procedure. Conclusion. We demonstrated in a small cohort of patients that early laparoscopic cholecystectomy is safe and can be performed quicker with the aid of fluorescent dyes. In order to challenge the safety paradigms around the early laparoscopic cholecystectomy a larger study is necessary.
... Thus, it results in formation of short CA; and because of which RHA may be mistaken for CA leading to its inadvertent ligation during procedures like cholecystectomy. 16,17 The right hepatic artery is an end artery and injury to which causes necrosis of the right lobe of the liver. The "caterpillar hump" RHA is susceptible to iatrogenic injuries causing serious haemorrhage. ...
Laparoscopic cholecystectomy (LC) is the most commonly performed surgical procedure and considered as the gold standard treatment of gallstone disease. However, the overall rate of complications like injury to bile duct and hepatic artery in LC remains higher than that seen in open cholecystectomy. Hence complete knowledge of the anatomy and anatomical relationship of biliary tree and liver plays a key role in the laparoscopic hepatobiliary surgeries. Being an end artery, blood supply to the right lobe of the liver solely depends on the right hepatic artery. Identification of variations in hepatic arterial anatomy is important in the planning and performing of hepatobiliary surgeries varying from simple LC to pancreaticoduodenectomy. In the current study, the authors referenced laparoscopic dissection results to examine another rare case showing "anterior" relationship of aberrant right hepatic artery (ARHA) with the common hepatic duct having clinically important implications in LC. The objective of this study is to highlight the importance of learning anatomy as the first step for a successful surgery and with the help of this case contribute to existing knowledge of the right hepatic artery to improve surgical safety.
... This observation might be explained by the fact that the gallbladder bed operation is mainly a detachment procedure, which is relatively simpler, and faster to stabilize. On the other hand, there are multiple anatomical structures to be exposed in the site around the cystic duct with considerable potential variations [19]. In addition, cholecystitis affects procedure diversity and amplifies the difference in its difficulty. ...
Background
The assessment of laparoscopic cholecystectomy (LC) skills using operating times has not been well reported. We examined the total and partial operating times for LC procedures performed by surgical trainees to determine the required number of surgeries until the surgical time stabilizes.
Methods
We reviewed the video records of 514 consecutive LCs using the three-port method, performed by 16 surgical trainees. The total and partial surgical times were calculated and correlated to the surgeons’ experience.
Results
The median total surgical time for a trainee’s first LC was 112 (range 71–226) minutes. It reduced rapidly after the first 20 LCs and plateaued to its minimum after approximately 60 cases. A statistically significant time decrease was observed between the first 10 (median, range 112, 46–252 min) and the next 50–59 cases (64, 34–198 min), but not between the 50–59 and the subsequent 100–109 cases (71, 33–127 min). The total times taken by trainees who had performed > 50 operations were not significantly different from those taken by instructors during the study period. Surgery for 125 patients with acute cholecystitis took a significantly longer time (median 99 vs. 74 min with non-acute cholecystitis); however, the abovementioned time reduction findings showed similar results regardless of the patient’s acute inflammation status. The partial operating times around the cervical/cystic duct and gallbladder bed reduced uniformly between the first 10 and the following 50–59 cases. Although time variations in total and cervical/cystic duct operating times were not correlated to the surgical experience, time fluctuation of gallbladder bed procedures reduced after 60 cases.
Conclusion
The time required to perform an LC was inversely correlated with the experience of surgical trainees and halved after the first 60 cases. The surgical experience required for LC time stabilization is approximately 60 cases.
... As a result, cholecystectomy for this condition is time-consuming, technically challenging, and associated with increased morbidity. 7 In the pre-laparoscopic era, patients of acute cholecystitis were initially treated conservatively so that the inflamed gall bladder "cools down", followed by cholecystectomy six weeks later. In 1966, D.M.Essenhigh reported that early open cholecystectomy for acute cholecystitis is as safe as delayed cholecystectomy with reduced morbidity and Hospital stay. ...
... Hartmann's pouch is mostly considered in the literature to be a pathological dilatation of the neck of the gallbladder due to the presence of stones and/or inflammation. A prominent Hartmann`s pouch (with our without a lodged large stone) can result in serious difficulties in intra-operative identification of the anatomy, grasping the gallbladder neck, lateral retraction of the gallbladder, dissection of the Calot`s triangle and even performing intra-operative cholangiogram [45]. On the other hand; a preoperative radiological finding of a gallbladder that appears to be smaller than the size of the gallbladder fossa with or without delayed filling of the fundus on high resolution ultrasonography and radionuclide hepatobiliary scan respectively, should alert the surgeon to a potentially challenging anatomy in the form of gallbladder Phrygian Cap [46]. ...
Over the past two decades, there have been an increasing number of reports describing a sixth type of choledochal cyst (cystic duct cyst) in adults that was not included in Todani’s classification. This sixth entity has not yet been systematically reviewed in the literature. We therefore explored this condition in adults from the perspective of the clinical presentation, diagnosis and treatment through a systematic review of the evidence. The final analysis included 33 reported cases, with 55% of them reported in Asia. The mean age was 39.3 years old, with a female-to-male ratio of 1.5:1. Magnetic resonance cholangiopancreatography was accurate in establishing the diagnosis in 69% of cases. Where reported, standard laparoscopic/open cholecystectomy was performed in about 74% of patients, while around 25% of them needed extensive surgery. Associated malignancy was reported in 6.1% of cases, while 28% of patients had co-existent gallstone-related disease. No significant post-operative morbidity or mortality was reported. In this era of emergency laparoscopic cholecystectomy, surgeons should be aware of this rare condition, with the particular understanding that it is associated with gallstone-related disease in a significant number of reported cases.
... The accessory RHA may be injured during resection of the pancreatic head because the artery lies in close proximity to the portal vein [1]. Due to the variant course, the RHA comes in close proximity to (CD) and the gall bladder, this results in formation of short (CA); thus, RHA may be mistaken for (CA) and inadvertently ligated during surgical procedures like cholecystectomy and liver transplantation [20] [21]. The presence of (RRHA) ...
... Finally, in the presence of complex cases in which we are faced with severe adhesions or frozen triangles, a call for help or a diagnostic certainty tool, such as a diagnostic cholangiography must be kept in mind. Remember that patient safety comes first [2,20]. ...
Introduction and importance:
One of the most important measures during the cholecystectomy procedure is based on a "Culture for Safe Cholecystectomy (CSC)". Vascular injury reports an open surgery conversion rate of 0 to 1.9% and a mortality of less than 0.02%. The caterpillar or Moynihan's hump configuration is characterized by a tortuous right hepatic artery (RHA) running proximal and/or parallel to the cystic duct and predisposes to a small and/or short cystic artery (CA).
Case presentation:
A 65-year-old woman with no relevant clinical history underwent a laparoscopic cholecystectomy (LC) for cholelithiasis; during the procedure a caterpillar or Moynihan's hump was identified.
Clinical discussion:
Anatomical variations represent 20-50% of all cases; therefore, CVS is required. The incidence of caterpillar or Moynihan's hump varies between 1% and 13% of all cases. To date, the scientific literature on this topic is limited. The most accepted etiology is related to embryological formation.
Conclusion:
Biliary and arterial variations are more frequent than we think, so an anatomical knowledge, CSC and CVS represent a fundamental rule, increasing the safety of the surgical procedure.
... Accidental injury or ligation of an aberrant bile duct as observed in the present case during cholecystectomy may result in severe complications such as biliary leakage and biliary cirrhosis [10,13,[16][17][18]. However, some researchers consider any bile duct activity from the right lobe of the liver and interaction with the CHD as aberrant. ...
Awareness of variations in the hepatic vasculature and biliary system is extremely important for avoiding iatrogenic injury in upper-abdominal surgery. The objective of this study is to describe a rare case of abnormal vascular and biliary structures in the hepatocystic triangle (HCT) (the modern Calot’s triangle). During anatomical dissection of the coeliac trunk (CT) in an old man, the authors observed the presence of a hepatosplenic trunk arising from the CT and bifurcating into common hepatic and splenic arteries. The common hepatic artery divided into hepatic artery proper and gastroduodenal artery. The presence of accessory right hepatic artery (ARHA) arising from the superior mesenteric artery was also notable. The aberrant artery ascended retropancreatically ventral to the splenic vein, then posterolaterally to the portal vein before termination into the right hepatic lobe in the HCT. Within this triangle, there was an aberrant bile duct originating in the right hepatic lobe and ending in the common hepatic duct. This accessory duct crossed the ARHA and an associated branch (the cystic artery). There is no known previous report on the co-existence of an ARHA and an aberrant bile duct within the HCT, in addition to the hepatosplenic trunk. The clinical implications of the current case are addressed in discussion.
... We first visualize the area of the common bile duct, the gallbladder neck, and Lund's or Mascagni's node often referred to erroneously as Calot's node [13]. This is an important landmark reliably located superior to the cystic duct, lateral to the common or right hepatic duct, and anterior to the cystic artery. ...
Background
Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC.
Methods
In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury.
Results
Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries.
Conclusion
Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.
... The cystic lymph node (CLN), also known as Calot node, Lund node, or Mascagni lymph node, has been described as a content of the Calot triangle. 2,3,7 Several studies [8][9][10][11][12] have demonstrated that it is commonly found near the cystic artery. It was, therefore, suggested that using CLN identification and ensuring all dissection is performed lateral to this may reduce the risk of BDI. ...
Background:
The cystic lymph node (CLN) represents an anatomic safety marker and a surrogate marker of technique during laparoscopic cholecystectomy (LC). We aim to demonstrate the value of CLN in comparison to the critical view of safety (CVS) and study the effects of increasing difficulty on the 2 approaches.
Methods:
A prospective study of consecutive LC was conducted. Patient demographics, type of admission, clinical presentation, operative difficulty grade, visualization of CLN, identification of CVS, operative time, and complications were recorded and analyzed.
Results:
Of 393 LCs, half of the admissions were emergencies. Thirty-four percent had obstructive jaundice or acute cholecystitis. The CLN was visually identified in 81.7% with a small difference between operative difficulty grades 1 to 3 versus 4 to 5. Although CVS was unachievable in 62 patients, 43 (69.4%) still had an identifiable CLN. The median operating time was 68 minutes with 1 mortality but no conversions or intraoperative complications.
Conclusions:
Identifying the CLN during LC could compliment the CVS in avoiding major ductal injury. Dissecting lateral to the CLN to commence the process of displaying the cystic pedicle structures may be a strategy in safely achieving the CVS. During the more difficult LC where displaying the CVS is impossible, the CLN may be the key anatomic landmark.
Background: The widespread use of surgical clips in laparoscopic cholecystectomy has been associated with various complications, including clip slippage, dislodgement, migration, ulceration, and necrosis of the cystic duct, which may lead to bile leakage. In response to these risks, clipless laparoscopic techniques, particularly the use of electrocautery, have been explored. While both monopolar and bipolar diathermy are used for tissue cauterization, monopolar systems pose a higher risk of lateral thermal injury to surrounding structures such as the common bile duct, hepatic artery, and bowel. Bipolar electrocautery, although safer, is not without drawbacks, including smoke generation that may hinder visualization during surgery.Aim: This study aimed to evaluate the efficacy and safety of bipolar electrocautery for controlling the cystic artery during laparoscopic cholecystectomy, and to determine whether it is a suitable alternative to conventional clip application.Methods: A prospective study was conducted on 100 patients undergoing laparoscopic cholecystectomy, who were divided into two groups of 50. Group A underwent surgery with clip application to control the cystic artery, while group B used bipolar electrocautery. Postoperative outcomes were assessed over a two-week follow-up period.Results: Mean operative times were 35.19 minutes in group A and 34.18 minutes in group B. Median ages were comparable between groups. One case of intraoperative bleeding occurred in group B and was successfully managed. No major complications or postoperative bleeding were noted in either group.Conclusion: Bipolar electrocautery is a safe and effective alternative to surgical clips for cystic artery control in laparoscopic cholecystectomy.
Background: Laparoscopic cholecystectomy has replaced open cholecystectomy as the standard treatment for cholelithiasis. However, it is associated with a higher incidence of common bile duct (CBD) injury. (LC) has become the preferred treatment for cholelithiasis; however, it carries a higher risk of common bile duct (CBD) injury compared to open cholecystectomy. It is a largely replaced open cholecystectomy (OC) but is associated with higher rates of common bile duct (CBD) injury. This study compares the frequency of CBD injury between the two techniques. To compare the frequency of CBD injury in open cholecystectomy versus laparoscopic cholecystectomy. Methodology: A randomized controlled trial was conducted at the Department of Surgery, People Medical College Hospital Nawabshah, from July 1 to December 31, 2020. A total of 320 patients aged 20–50 years with cholelithiasis were randomly divided into two groups: 160 underwent open cholecystectomy and 160 laparoscopic cholecystectomy CBD injuries were diagnosed clinically (jaundice) and confirmed via MRCP. Frequency of CBD injury was observed and analyzed statistically using SPSS 22.0, with significance at p ≤ 0.05. Results: Out of 320 patients (160 in each group) Mean age was 33.5±8.7 years; 54.7% were female, CBD injury was observed in 3.8% of patients in the open cholecystectomy group compared 9.4% of the laparoscopic group. The difference was statistically significant (p = 0.042). Indicating a significantly higher rate in laparoscopic procedures and those with diabetes had higher injury rates in the LC group. Conclusion: Laparoscopic cholecystectomy is associated with a higher frequency of CBD injury compared to open cholecystectomy. Enhanced surgical training and safety protocols are essential.
Background
The protective impact of the Critical View of Safety (CVS) approach on the vasculo-biliary injuries during laparoscopic cholecystectomy (LC) depends largely upon the understanding of the normal and variant anatomy. Structures exposed during the acquisition of the CVS can deviate from the typical dual configuration of the cystic duct and artery (gallbladder pedicle) representing either a third (supernumerary) or atypical in course (heterotopic) element. The aim of this study was to determine the identity and the frequency of these anatomical elements and to propose anatomic schemata that can guide the achievement of CVS by surgeons.
Method
Fourteen anatomic elements that can be encountered during LC were defined by members of the Hellenic task force on the typology of safe cholecystectomy using a literature review and expert consensus. Videos of 279 LCs performed for biliary colic were reviewed noting the presence of a third and or heterotopic anatomic element. In 108 LCs these elements were sought also intraoperatively. A CVS score according to Sanford and Strasberg was assigned to each video.
Results
The normal configuration of the gallbladder pedicle was present in 233 cases (83.51%). A third element was detected in 42 cases (15.05%) and was arterial in 41 cases and biliary in 1 case. A heterotopic course concerned exclusively the cystic artery in 24 cases (8.6%). Neither of these two variant patterns compromised achievement of the CVS during LC. CVS scores improved with the addition of intraoperative assessment.
Conclusion
Typical and aberrant anatomy of LC was defined and anatomic schemata proposed to help the surgeon better understand aberrant anatomy and confidently and safely handle any encountered element that deviates from the normal configuration of the gallbladder pedicle during laparoscopic cholecystectomy.
Background
Laparoscopic cholecystectomy is the gold standard in the treatment of symptomatic gallstones. The large number of gallbladders removed every year is not fully consistent with the excessively high incidence of iatrogenic bile duct injury (IBDI). Several strategies have been suggested to reduce this risk. Among them, the use of extra biliary anatomic structures, such as the Rouvière’s sulcus, as a landmark to guide the surgeon during dissection has been proposed as a means to prevent IBDI. The main aim of the present paper is the evaluation of the prevalence of Rouvière’s sulcus (RS) and its anatomic variants in a given population.
Materials and Methods
This observational, cross-sectional, and multicenter study has been conducted at the Department of Digestive and Emergency Surgery of the “Azienda Ospedaliera Santa Maria,” Terni (Italy), at the Department of Surgical Sciences of the “Azienda Ospedaliera Perugia,” Perugia (Italy) and at the Department of Emergency and Trauma Surgery of the “Policlinico Umberto I,” Rome (Italy). Intraoperative images of 111 patients undergoing laparoscopic cholecystectomy were analyzed to identify the presence and type of RS, according to the Singh-Prasad classification and the Dahmane classification.
Results
RS was present in 93 (83.8%) patients. Singh-Prasad type 1A is present in 48.4% of patients, type 1B in 25.8%, type 2 in 12.9% and type 3 in 12.9%. Dahmane’s open type is present in 48.4% of patients and fused type in 51.6%.
Conclusion
Due to its high prevalence, RS can be used as an anatomic landmark and probably reduces the incidence of IBDI during laparoscopic cholecystectomy.
Importance of establishing the Critical View Of Safety in order to perform a safe Laparoscopic Cholecystectomy
Objective: To know in detail the level of origin, course and relation of the cystic artery and to assess frequency of the anatomical variations of cystic artery in hepatobiliary triangle observed during laparoscopic exposure for the guidance of laparoscopic surgeons. Study Design: It was a descriptive cross-sectional study in 6oo patients. Place and Duration of Study: This research work was undertaken in five teaching hospitals with adequate facilities and skillfull surgical team, from 8th Jan 2011-15th Jan 2014. Methadology: Surgical management of Six hundred patients with laparoscopic cholecystectomy was done from 8th April 2012 to 9th April 2014 prospectively. The Stryker, American laparoscope of 30° was employed in this study. We selected patients on the basis of non-probabilty convenient sampling technique. The DVD recorder was used to display course and relations of cystic artery and its variations on endoscopic visualization. using Medical grade video monitor was practiced to display and document anatomical variations. Photographs of each observed anatomical variation was taken. Results: Our experience with 600 laparoscopic cholecystectomies has revealed that anatomic variations of the cystic artery occur frequently. Overall results demonstrated 24% variations in the origin, course, relation of cystic artery in hepatobiliary triangle.In 76% of patients we demonstrared usual anatomy of cystic artery. Conclusion: Laparoscopic surgeons must know origin, course, relation of cystic artery and its variations to avoid vascular injuries, which can cause serious hemorrhage during laparoscopic cholecystectomy and to prevent postoperative complications. These injuries can result into significant morbidity and even mortality.
Anatomy has remained an interest of physicians throughout the ages. The biliary tract spans from the liver to the hepatoduodenal mesentery, pancreas, and into the duodenum. Therefore, it is important for not only hepatobiliary surgeons but also general gastrointestinal surgeons, gastroenterologists, radiologists, and pathologists to be familiar with biliary anatomy and its variants. While surgery for hilar cholangiocarcinoma is one of the most challenging procedures, cholecystectomy is one of the most common procedures done from the beginning of surgical training. We hope that by answering the following questions, you will gain a comprehensive understanding of biliary anatomy and a greater appreciation for it.
Background & Aims: The gallbladder and biliary tract are structures that are in close proximity to the adjacent organs and can exhibit a variety of anomalies and anatomic variations. However, the literature on morphological variations of the gallbladder and their prevalence are limited. This study aims to identify various anatomical variations in gallbladder shape and position that should be considered for clinical implications, investigative procedures, radiological studies, surgical interventions, embryological explanations, and comparative anatomy. Aim of this study is to study the morphology of gallbladder in cadavers.
Materials & Methods: This study was done on 100 cadaveric liver and gallbladder specimens available in the Department of Anatomy, Sri Devaraj Urs Medical College, Kolar, India. Parameters such as maximum transverse diameter and maximum length were measured with help of metallic tape. Each specimen was studied for morphological variations. The observations were tabulated and analysed statistically.
Results: Gallbaladder samples had length ranging between 3.3 and 12 cm, transverse diameter between 2.0 and 5.0 cm. The commonest shape observed in this study was pear shaped in 84% of cases. The length of gallbladder below the inferior border of liver varied between 0.4 and 2.5 cm.
Conclusion: The anatomic variations of the gallbladder and biliary tract are critical during their surgical procedures. The present study describes the different anatomic variations of human gallbladder and its clinical importance. This study will greatly assist surgeons in understanding the possible morphology of the gallbladder.
Background: The extra hepatic biliary apparatus consists of right and left hepatic ducts, common hepatic duct, gall bladder, cystic duct and common bile duct which collects and delivers the bile from liver to second part of duodenum. Anatomical variations of biliary tree occur with sufficient frequency to be of concern to the surgeons operating in this area. Identification of anatomical details is necessary for accurate detailing of biliary tree to avoid inadvertent damage to biliary ductal system. Objective: To study the normal anatomy and variations of gall bladder by dissection method. Methods: In the present study a total number of 50 adult human livers with lesser Omentum, duodenum and pancreas were collected from the dissected cadavers from the department of anatomy KVG Medical College Sullia and Chamarajanagar institute of medical sciences, Chamarajanagar. The various parameters of the gall bladder and biliary ductal system were recorded and photographed. Observations and results: The following variations were observed in the present study. Hartmann’s pouch was observed in 42% (21/50). Hourglass GB was observed in 2% (1/50). Folded fundus was observed in 2% (1/50). Intrahepatic GB was observed in 4%.
Objective: To assess the frequency of cystic lymph node within the Calot’s triangle and to
identify the relation of Cystic artery with cystic lymph node.
Study design: Cross Sectional study.
Place and Duration: Th is study was done at the department of surgery Dow University of
Health Sciences (DUHS) and civil hospital Karachi from September 2011 to April 2013 (series
2).
Methodology: Non probability, purposive sampling technique was used for sample collection.
Th e samples were 300 diagnosed cases of Cholelithiasis, undergoing Laparoscopic Cholecystectomy
in Civil Hospital Karachi and other private hospitals of Karachi. Laparoscopic
Cholecystectomy was performed under general anesthesia using the four port technique. Th e
information of anatomy on endoscopic visualization was recorded by DVD recorder aft er taking
the informed consent of the patient. Over all frequencies of cystic lymph node were noted
and the relation of it were identifi ed with cystic artery.
Results: SPSS (version 16) was used in the analysis. Overall frequencies of the cystic lymph node and relations of the variation were noted. Out of 300 cases there were 53.33% cases having a lymph node in Calot’s triangle and 46.67% (n=140) cases with no lymph node in the
Calot’s triangle. Out of 160 cases with lymph node, there were 40.6% cases with a cystic artery
anterioinferior to the lymph node and 59.4% cases having cystic artery posterioinferior to the
lymph node
Conclusion: We found cystic lymph node in more than half of the cases. We also found a
signifi cant relation of the node with the cystic artery. Surgeons can use the lymph node as a landmark for the identifi cation and clipping of the cystic artery. Th is information will be helpful in the safe procedure of the laparoscopic cholecystectomy.
Laparoscopic cholecystectomy has become the standard operation for symptomatic cholelithiasis and other biliary disorders. This chapter describes the standard four-trocar technique for safe laparoscopic cholecystectomy as well as potential pitfalls and strategies to avoid complications.KeywordsLaparoscopic cholecystectomyGallbladderLaparoscopyCholecystectomyCholecystitisCholelithiasis
Introduction
The cystic artery continues to be a significant structure visualized during laparoscopic cholecystectomy. Despite numerous reports on the variable anatomy of the cystic artery, only a few discuss the liver parenchyma that developed as an accessory to the cystic artery.
Case presentation
I present a middle-aged patient who had an elective laparoscopic cholecystectomy by blunt dissection to separate tissues in the surgical field surrounding her gallbladder. The inferolateral liver parenchyma segment 5 accessory cystic artery was visualized and clipped safely.
Conclusion
Blunt, careful dissection of the inferolateral aspect of the gallbladder may reduce the chance of bleeding due to aberrant dissection with abnormal blood supply to the gallbladder.
Objective: To compare the morbid anatomy and iatrogenic problems and complications encountered during laparoscopic cholecystectomy (LC) in both genders.
Study Design: A cross sectional analytical study.
Place and Duration of Study: The study was conducted at Pakistan Air Force Hospital, Islamabad, from May 2017 to Jan 2019.
Methodology: All patients who underwent LC during our study period were included in the study. A predesigned proforma was used to record data. The cases were divided into two groups based on gender. The parameters studied for each group included appearance of gallbladder, intra operative bile leakage, requirement of hemostatic procedure, spillage of stones, multiplicity of stones i.e. single vs. multiple, operative time and need of drain placement.
Results: A total of 120 patients were included in the study. There were 21 (17.5%) male and 99 (82.5%) female subjects. The mean age was 43.66 ± 13.8 years with range of 11-74 years. Normal looking gallbladder was more common in females. Thick walled gallbladder was less frequent in females (males 66.7% vs. females 39.4% p=0.043) Intraoperative complications were more in males. There was no statistically significance gender difference in number of stones, spillage of stones and need for hemostasis.
Conclusion: Symptomatic gallstones were mostly found in females. Gender differences exist as regards the apparent morphology & difficult operative factors. Performance of LC in our setup is of a standard comparable to those of other centers. Since morbid anatomy of females is more favorable, so surgeons new to LC should be encouraged to perform surgery on female patients.
Diabetic food challenge
Operative complications are an inherent risk in all surgical approaches. With the advancement of technology comes a departure from technical comfort zones, and frequently a steep learning curve as new practices are adopted. To successfully execute safe surgeries, the importance of a team approach cannot be overemphasized. All team members must be trained and comfortable with robotic surgery and able to navigate technical dilemmas as they arise in the operating room. In this chapter, we present common complications across the field of robotic surgery, and review recommendations for their prevention and treatment.
Background and Aim
Cystic artery (CA) is one of the important structures to be ligated during cholecystectomy. Recurring complications such as hemorrhage or liver injury has attracted surgeons, radiologists, and anatomists to do research on the topic.
Materials and Methods
Thirty-two formalized cadavers were used for this study. After opening the abdomen, lesser omentum was separated, followed by fine dissection of CA. Findings were recorded and variations were photographed. The collected data were analyzed, and the prevalence was expressed as percentage.
Results
In 68.75%, single CA was passing through the Calot's triangle (CT), and in 4.5%, double CA was passing through the CT.
Conclusion
Accurate knowledge of CA anatomy is essential to avoid iatrogenic extrahepatic biliary injuries in surgeries related to this region. We have focused to explore CA variations to help the surgeons and radiologists.
The anatomy of the gallbladder and biliary tract is complex and displays a wide range of variations. Anatomical variations with clinical significance are found in 20% of laparoscopic cholecystectomies. Common iatrogenic injuries are directed towards the biliary tree and surrounding blood vessels, with such injuries possibly causing severe morbidity and life-threatening situations. As misinterpretation of anatomy can contribute to surgical complications, it is crucial for surgeons to have a clear understanding of the underlying anatomy as well as be aware of possible anatomical variations to ensure the best results for their patients. Detailed knowledge of the anatomy is provided for surgeons to avoid potential complications and perform a successful procedure.
Of all the complications of laparoscopic cholectecystomy, bile duct injury (BDI) is the most serious complication. The prevention of injury to the common bile duct (CBD) remains a significant concern in laparoscopic cholecystectomy (LC). Different kinds of methods have been advanced to avoid this injury but no single method has gained wide acceptance. Because of various limitations of current methodologies we began a study using cold light illumination of the extrahepatic biliary system (light cholangiography LCP) to better visualize this area and thereby reduce the risk of bile duct injury.
Thirty-six patients with cholelithiasis were divided into two groups. Group I (16 cases) received LCP and group II (20 cases) received methelenum coeruleum cholangiography (MCCP). In group I cold light was used to illuminate the common bile duct by leading an optical fiber into the common duct with a duodenoscope at the time of LC. The light coming from the fiber in the CBD could clearly illuminate the location of CBD and hepatic duct establishing its location relative to the cystic duct. This method was compared with the dye injection technique using methelenum coeruleum.
In group I thirteen cases were successfully illuminated and three failed. The cause of three failed cases was due to the difficulty in inserting the fiber into the ampulla of Vater. No complications occurred in the thirteen successful cases. In each of these successful cases the location of the common and hepatic ducts was clearly seen differentiating the ductal system from surrounding anatomy. In ten cases both the left and right hepatic ducts could be seen and in three only the right hepatic ducts were seen. In four of the thirteen cases, cystic ducts were also seen. In group II, eighteen of the twenty cases were successful. The location of extrahepatic ducts became blue differentiating the ductal system from surrounding anatomy. Two cases failed due to a stone obstructing the cystic duct, and extravisation of the dye turned the entire area blue. LCP showed the common and hepatic ducts more clearly than MCCP.
LCP is the only technique that can clearly and directly show the location of the extrahepatic biliary system and may be useful in selecting cases of uncertain anatomy in the prevention of bile duct injury.
The rapid increase during recent years in the number of operations on the gallbladder and bile ducts has been accompanied by the report of a series of cases of injuries to the ducts and of severe hemorrhage from vessels in their vicinity.This subject is of the utmost importance to every surgeon and merits a closer study of the causes of such accidents and of their prevention in the future.Eliot1 has recently collected all of the published case reports of injuries of the bile ducts during operation. Twenty-one of twenty-three accidents occurred during cholecystectomy, and the remaining two during pyloric resections for cancer. There were three types of injury to the hepatic and common ducts: (a) removal of a portion of the wall; (b) complete division, and (c) removal of the junction of the cystic and hepatic ducts.The most important factors in the etiology of such injuries
Major biliary complications of laparoscopic cholecystectomy may be prevented by an understanding of extrahepatic biliary ductal and arterial anatomic relationships. The common patterns of anatomic variations important to the surgeon performing laparoscopic cholecystectomy are reviewed with respect to recently reported biliary injury during this procedure. Recommendations for delineating biliary anatomy and avoiding laparoscopic complications are reviewed.
Injury to the bile ducts is the most important complication of laparoscopic cholecystectomy (LC), affecting approximately 2000 patients annually in the United States. Traditional surgical teaching fails to provide adequate extrabiliary reference points. A "person approach" of blame and shame (as distinct from a "system approach") has evidently been unsuccessful in controlling this problem. New strategies are needed. High-reliability organizations such as aviation and the nuclear power industry have well-developed system-based error prevention programs; the application to laparoscopic operations of some principles used in these programs merits evaluation. In addition, some time-honored teaching of steps to safeguard the bile duct needs to be re-examined.
A review of the literature and of 34 cases of bile duct injury referred to the author was carried out. Traditional surgical teaching was evaluated to identify reasons why it has failed to prevent bile duct injury. New extrabiliary reference points were used. Error prevention strategies derived from the aviation and maritime industries were modified for application to LC. These principles have been applied in a prospective study of 2000 successive LCs carried out on 1 surgical unit, including operations by surgical trainees.
The literature and case review indicated that misidentification of biliary anatomy was the major cause of bile duct injury and the injury was unrecognized by the operating surgeon in 3 out of 4 cases, suggesting that traditional surgical teaching provides inadequate reference points to prevent duct misidentification, that spatial disorientation analogous to navigation errors occurs, and that systemic factors predisposing to error are present. Several principles used in navigation were applied. "Human factors," educational principles derived from aviation crew resource management training, were applied. No bile duct injuries occurred in the 2000 LC operations. Eight patients had biliary leakage develop but all recovered without further surgical intervention.
Laparoscopic bile duct injury continues to occur at an unacceptable rate. New strategies involving a system approach and using principles adopted by the aviation and maritime industries were applied in 2000 consecutive LCs without bile duct injury. The application in the operating room of commonly taught navigation principles, the use of extrabiliary reference points such as Rouvière's sulcus, and the introduction of human factors education for surgeons reduces the frequency of bile duct injury.
To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury.
Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error.
The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations.
The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot.
These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.