CASE REPORT - OPEN ACCESS. Contents list available at ScienceDirect International Journal of Surgery Case Reports ELSEVIER journal homepage: www.casereports.com A ‘critical view’ on a classical pitfall in laparoscopic cholecystectomy! Doone Tomasz Dziodzio**, Sascha Weiss”, Robert Sucher*, Johann Pratschke*, Matthias Biebl* « bepromen of enero Visceral and Tonplan Surgery Chant Beri, Germany ° Depertmen of rea, Treeplon. and Thora Suge Inner Meal Univer Ineric Aig ARTICLE INFO ABSTRACT ‘Accepted November 2034 INTRODUCTION: Laparoscopic cholecystectomy ithe most common laparoscopic surgery performed by general surgeons. Although being routine procedure. clasial pitfalls shal be regarded, as mispercep. tlonof intraoperative anatomy sone ofthe leading causes oft duct inures The eritial ew of safety” in laparoscopic cholecystectomy serves the unequivocal identification ofthe cystic dc before wansec tion. The aim ofthis manusespe sto discuss classical pitfalls ane ble dct injury avoiding strategies in Inparoseopic cholecystectomy, by presenting an intresting ase report. ‘PRESENTATION OF CASE:A 71-year-old patient, who previously suffered from abillary pancreatitis under~ ‘went laparoscopic cholecystectomy after ERCP with stone extraction, The intraoperative its showed 4 shrunken gallbladder. After placement of four trocas, the gallbladder was grasped inthe usual way {atthe fundus and pulled inthe right upper abdomen. Following the dissection ofthe triangle of Clot, 12 Veitcal view of safety” was established. As éissection continued. it however soon became clear that Instead of the cystic duet. the comiman bile duct had been dissected. In order to create an overview. the zallbladder was thereatter mobilized funds fest an further preparation restme carefully to expose the eystic duct and the common bile duct. Consecutively the operation could be completed in the usa DISCUSSION: Despite permanent inetease i lating eves and new approaches i laparoscopic teh rigs, bile duct injuries stl remain twice as frequent a in the conventional open approach, Inthe ‘ase presented, transection of the common ble duct was prevented through citieal examination af the present anatomy. The “critical view of safety” certainly offers nota ful protection tavoid biary lesions, but may lead to significant rik minimization when consstenely implemented CONCLUSION: A suticient mobilization of the gllladder from its bed is essential in performing critical view in laparoscopic cholecystectomy. {© 2014 The Authors Published by Elsevier Ltd. on behalf of Surgical Acocites Lt. This is an open. Lapazescopiecheleeystectmy access article under the CC BY-NC-ND license hp: creativecommons orglicensesiby-ne-nd{3.0)}. 1. Introduction, The advent of laparoscopic cholecystectomy in the early 1990s led to a paradigm change and a shift from open approach towards minimally invasive techniques.’ Meanwhile, the laparoscopic cholecystectomy is the most common laparoscopic procedure iy general surgery and considered to be the gold standard in the treatment of symptomatic cholelithiasis and acutejchronic cholecystitis”? The laparoscopic technique results in lower post- ‘operative pain, shorter hospital stays and a proper cosmesis.” in times before the laparoscopic era the incidence of biliary injures ater conventional open cholecystectomy amounted ~0.2%.° How- ‘ever. despite of contemplated advantages, a rapid learning curve and constant improvements in methadology. the complication rates ofbile duct injuries after laparoscopic cholecystectomy cout from 0.4% to 0.5%, dependent on the underlying disease and remain * corresponding uth npydadotorgsi0so1s) sper 200411018 422}0-261296 2014 The Authors. Pubined by Elev hp jreatveromens rgeensesfy nen.) higher than in the open approach.*!° The most common cause of serious biliary injury is misidentifcation.!" Due to abovementioned significant divergence between open and laparoscopic procedures Strasberg and colleagues in 1995 first suggested a three-pronged strategy called the “critical view of safety” (CVS), to minimize the risk of bile duct injuries in laparo scopic cholecystectomy. © This technique follows three principles (1) dissection ofthe triangle of Clot fromallfaty and fibrous tissue, (2) mobilization of the lowest part ofthe gallbladder from its bed and (3) the unambiguous identification of two and exclusively of| two structures (cystic duct. artery cystica) entering the gallbladder Ig. 1} In the following case report we highlight the importance of the VS in laparoscopic cholecystectomy and its classical pitfalls 2. Case report ‘A 71-year-old patient presented with upper abdominal pain in our outpatient department. The patient suffered from coronary heart disease and benign prostatic hyperplasia, there wasnobistory sd on bebal of Surgical Asocates Ut Tis i an open acess ale under the CC BY-NCND lenseDao eal./inernationa Jounal Srzery Cose Reports (2014) 118-1221 ims. Fig 1. cial wew ofsaety by Strasberg eal he unambiguous exposure of itr Fig. Atempt ofthe “stil view af safety” = ony one stratre entering the slbladde canbe clely deta of relevant pre-existing surgical conditions. After blood analysis revealed following results: pancreatic~amylase: 1214UjL (nor- ‘mal range: 13-53 Uj, -lipase: 2619 U/L [13-60 UL], gamma-cr 500 U/L [10-71 Ujt] and abdominal ultrasound showed presence of gallstones in the gallbladder and dilatation of the com- ‘mon bile duct 2 magnetic resonance cholangiopancreatography (MRCP) was performed. Following the diagnosis of choledo- cholithiasis a papillotomy with stone extraction via endoscopic retrograde cholangiopancreatography (ERCP) was executed. After an uneventful post-interventional period of two months laparo- scopic cholecystectomy was conducted ‘The patient signed a patient consent form and laparoscopic cholecystectomy was caried out in a classical four-port technique. {After establishment of a pneumoperitoneum and installation af all four ports, a shrunk gallbladder was found [Fig, 2}. First, the gall- bladder was grasped in the usual way a the fundus and pulled into the tight upper abdomen, followed by dissection of the triangle of Calot [Fig 3], Despite adequate preparation and removal ofall fatty and fbrose tissue only one structure entering the gallblad der was identified [Pig 4]. Initially this formation was interpreted as the cystic duct. However, on the one hand the putative cystic uct appeared of strong calibre, on the other hand a successful at cralization of the gall bladder could not be performed. To provide clear anatomical conditions, the gall bladder was entirely dissec- ted from its bed in a fundus frst-approach [Fig. 5]. The initially ‘misinterpreted structure, was now unequivocally identified as the ig 5 “tical view ost” —ll structures esti dc, camman ie dt} ean De every eee real wens pepo te b edo te ‘common bile duct. Preparation was continued and finally the cys- ‘uc duct, showing a long-segment adhesion with the common bile duct was properly identified in terms of a CVS, secured with clips and divided, Following haemostasis of all bleeding sites, inspectionCASE REPORT - OPEN ACCESS. i "ride ea teratonal Journal of Surery as epatsS(2014) 1218-1221 of the dissected cystic artery and cystic duct, retrieval ofthe gall bladder and drainage insertion the procedure could be Gnished in ‘a conventional manner. Drains were removed on 2nd and 3rd postoperative day. The patient was dismissed on 7th postoperative day alter an unremark- able postoperative course. 3. Discussion Nowadays laparoscopic cholecystectomy is regarded as the gold standard in the treatment of gallbladder diseases. According to German Census Bureau 194,000 cholecystectomies are performed analy in Germany,” The ratio of laparascopie procedures aver- ages between 90 and 95%.!" An initial rate of bile duct injuries from 0.74z to 2.8% at the onset ofthe laparoscopic era, could be reduced steadily to about 0.4% nowadays. Nonetheless, despite per- manent increase in learning curves and new approaches, bile duct injuries still remain twice as frequent asin the conventional open approach, The introduction of Strasbergs’ CVS could not approxi mate the original 0.2% rate of bile duct injuries, Howbeit data show, that a consequent use of CVS technique may prevent some biliary injuries, there is no Level I evidence that this technique prevents bile duct injuries in general. as there are no randomized trials pub- lished up to date."""* The question remains to what extent we surgeons are willing to accept complications when adopting new surgical techniques. Considering minimally-invasive procedures, the assumed benefit of lesser trauma to the patient always has tobe balanced against such - undisputable - higher complication rates ‘compared to an open approach, no matter how low the total event rated may be. Like in the case with CVS, strict adherence to such safety nodal points throughout the procedure may help narrowing the gap between complication rates of open and minimally inva sive procedures into acceptable bounds. This subject, which has sivenrise toconsiderable debate,isavery crucial one, as minimally- invasive methods more and more replace or supplement traditional ‘open surgical approaches, In the case presented, transection ofthe common bile duct was prevented through critical examination of the CVS. However, the importance of the CVS shal not be touted as a dogma, Instead, we recommend to use it as a framework, which shall help the sur _geon to Fe-evaluate each surgical step before proceeding, Different anatomies can lead to misinterpretations and lead to pitfalls in hasty preparation situations. Injuries ofthe common bile duct are the most frequent bile duct injuries described in literature ranging fom 66% to 72% of al bile duct lesions.” Compliance withall three criteria of the CVS may prevent inadvertent bile duct injuries. as itindicates reliable exposure and identification ofall structures in the triangle of alot Reported short-term mortality of accidental bile duct injury is approximately 1.9%." However, morbidity is muich higher, Only 1/3 of all injuries can be treated by ERCP and stenting, In 2/3 of all patients a further surgical biliary reconstruction is necessary. Here the median hospital stay extends for 8 more days." Its iffi- ‘cult to number the impact of these complications on the economy, StephanB, Archer andcolleagues estimated atotal annual economic ‘damage of approximately $40 million in the US. at 600-700 bile ‘duct injuries." The CVS certainly offers not a full protection to avoid biliary lesions, but may lead to a significant risk minimization when ‘consistently implemented, Unfortunately, it can be assumed that probably misperception, rather than technical errors are the lea ing cause of biliary injuries, as most bile duct lesions occur to experienced surgeons (>200 cholecystectomies performed).'” Therefore, we believe that a consistent adherence of established ‘guidelines in surgery is of particular importance. 4, Conclusion The rate of bile duct injuries after laparoscopic cholecystectomy averages around 0.4% and can lead to far-reaching consequences for the patients in the postoperative course. The “riical view of safety’ canbe used asa safe toolto prevent bile duct injury and classical pit- falls under critical evaluation ofthe surgical process. An adequate ‘mobilization of the gallbladder from ts bed and unambiguous iden- tification of the structures entering the gallbladder shall always be ensured. Conflict of interest None of the authors has any conflict of interest to disclose regarding this manuscript. Funding None, Ethical approval ‘Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy ff the written consent is available for review by the Editor-in-Chief ofthis journal on request. ‘Author's contributions ‘Tomasz Dziodzio: writing the paper. Sascha Weiss: proof reading, photo editing, Robert Sucher: writing the paper. Matthias Bieb!: writing the paper, proof reading, Johann Pratschke: proof reading. References a. Mae say ding laparoscopic ca eystetomy 152011 15322 5 Soper Stockman P,Dunsegan DL Asie SW. Lapuoscopl eleestee tony the nen gle sada Arch Sug 98227317 Serene 8D” age SB. Dot) Hyer, Hanks B.fnes 85. Lapatscepic holeystectany-Treatinent of hace fo symptomatic ees. An Sure ‘woes Sige SW, Hain, Elman. Sete JS. Unger HN, Lapare- Seopie chaecystctmy: the procedure ocho for aie coleesils An] Goxventes) 1985°98534 Wire; Mace Ninen Sander Varma King FM Lapaorcanic inayiees tos 398 Adams ian face lee ny ig pe 9. olin Caley MPs iy lowing apenas vo. Hut Howard opel Shean’ Meleny Wi J et a SRE eageeace a ge ey vl ee cent Ende Serasbergs, Brut IM Rational and usefshe crcl view effet ilapar- Seopicchelecstecony Jn Cal Surg 2010.21 132-8 12. Seasbery Sh Her Me Spec NA analysis the problem of Bary inury fang aparascopiehleeysectomy J4m Col Sure 1895.190:107-25, 13, Gesundhetabennterstattng ds Bundes hes vor tastscen Bundesamt wor ge bune de 14 Ge ete ening). aonaee J, Weigand K Kipler Ke a Aete ley eat se ere chyecony amas andereCASE REPORT —- OPEN ACCESS. Dao eal./inernationa Jounal Srzery Cose Reports (2014) 118-1221 22t 15, Avgtios KelgoglD.Tououms Z Batata Derveass C. One heusané 17, Aeher SB, Seow DW, Smith CD, Branum GD, Hunter JG. Be duct iajty UGpuroscopc coleystectomuesinasnge sutgcaluni wing thecal ew during lapatescopie bolcytecoy este of 2 national sire an Su ste technige, | stots Surg 3003.13498-503, Soot aaa 38 16, Yegants 5, Cains JC Operatve strategy can rede che iniéence of 18 Pet HA. Shenan S, Johnson MS, Hollenbeck AN. Cee J, Daum NM a mao: ble duet inary in laparescopc eholcstetmsy. AN Surg 208.78 Improved outcomes of ducnjres ie 21s century. Ann Sig 2013258 on 08 Open Access This article is published Open Access at scienceditect.com, It is distributed under the {SCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited,