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Safe Cholecystectomy CCX
Safe Cholecystectomy CCX
Aims and objectives <2 cm as short and >4 cm as long CD. The CD that required large
(L) size Hemolok (Weck, nonabsorbable polymer ligating clip), LT
In a prospective study we have attempted to identify the anatomical
400 ligaclip (Ethicon Endosurgery ltd) or suture ligation, was con-
landmarks and the bilio-vascular anatomy (BVA) that presents
sidered wide. The CA was isolated close to the cystic LN. Its
when the principles of safe cholecystectomy are followed and docu-
course and branching (when present) in the HCT were meticulously
ment the variation of the anatomy and classify it in the con-
dissected and noted. Based on the observed pattern, we have
text of LC.
suggested a classification of the CA. The GB was dissected off its
bed to complete the requirements of CVS. Presence of any addi-
tional biliary or vascular structure was noted. When conventional
Material and methods dissection appeared difficult, the CA was isolated, clipped close to
In a prospective study all consecutive patients who underwent LC GB surface or lateral to the cystic LN and divided. This (artery first
during March 2020–January 2023 were included. LC was per- technique) often facilitated dissection of the HCT to achieve CVS.
formed with strict attention to the principles of safe cholecystec- However, in case of severe inflammation, fibrosis, and obliteration
tomy.1 All surgeries were either performed or supervised by the of the HCT, a retrograde dissection (fundus first) was attempted
senior most surgeon in the team. The fundus of GB and Hartman’s that often ended in subtotal cholecystectomy. All stones were
pouch were grasped and appropriately retracted to identify the ana- retrieved from the remnant infundibulum which then was suture
tomical landmarks i.e. Rouviere’s sulcus (RS), the cystic lymph approximated or closed with endo-loop. The entire surgery was
node (LN) and the structures in the hepatoduodenal ligament. Dis- video recorded for review, analysis and confirmation of the opera-
section was started close to GB surface remaining strictly ventral to tive anatomy when required.
the RS. The HCT was approached from both anterior as well as
posterior aspect to clear all the fibrofatty tissue, leaving behind the
Results
CD and CA. The CD was dissected from infundibulum downwards
as far safely as possible with no attempt to define its junction with A total of 500 patients (male 180, female 320, mean age 48 years,
CBD. The dissected length of 2–4 cm was considered normal, and range 18–82 year) were included in the study.
Fig. 1. Types of Rouviere’s sulcus (RS): (a) Absent or rudimentary sulcus. (b) Medial end of the sulcus open, (c) Medial end fused. (d) Sulcus fused in the
middle. (e) Slit—small and shallow (<1 cm) sulcus away from the hepatic hilum. (f) Scar-completely fused sulcus, appearing as a white linear scar.
(g) Double sulcus. (h) Sulcus not identifiable
Table 1 Rouviere’s sulcus (n = 500): Various types as per Ibrarullah & was absent in 117 (23.4%) patients and could not be delineated in
Sikora’s classification11 and the respective incidences 77 (15.4%) due to subhepatic adhesions. When visible, a well-
Type Description n % formed sulcus—Type 1 was the most common variant. Double sul-
cus (type-4) was noted in one patient only.
0 Absent or rudimentary sulcus (Fig. 1a) 117 23.4
1 Deep sulcus 263 52.6 Various patterns of the CD were observed and documented as in
a. Medial end of the sulcus is open (Fig. 1b) 198 39.6 Table 2. CD was considered normal in 339 (67.8%) patients and
b. Medial end of the sulcus is fused (Fig. 1c) 57 11.4 absent in one patient. Wide CD with normal length was the most
c. Sulcus is fused in the middle (Fig. 1d) 08 1.6
2 Slit—small and shallow (<1 cm) sulcus away 25 5 common variant (14.2%). Wide CD was a result of calculi in 9 and
from the hepatic hilum (Fig. 1e) choledocholithiasis in 16 patients. It was not safe to dissect due to
3 Scar—completely fused sulcus, appearing as 17 3.4 inflammation and/or fibrosis in 29 (5.8%) patients
a white linear scar (Fig. 1f)
4 Double sulcus (Fig. 1g) 01 0.2 The CA was identified close to the cystic LN. Small branches
NI Sulcus is not identifiable because of 77 15.4 supplying the CD were noted before the artery divided close to the
subhepatic adhesions (Fig. 1h) GB surface into superficial and deep branches (Fig. 2a). The super-
ficial branch supplied the GB neck and infundibular region. The
deep branches running between GB and liver bed ended in GB wall
or mesentery or into the liver bed. Depending on its number and
Eighty-one patients were operated for acute cholecystitis. At sur- course in the HCT, the CA was classified into four types. The clas-
gery, four patients were identified to have cirrhosis of liver. Extra- sification and the respective incidences have been presented in
hepatic portal vein thrombosis and left sided GB was detected in Table 3. Type 1s was the most common variant found in
one patient each. 384 (76.8%) patients. Multiple arteries in HCT due to early division
Rouviere’s sulcus was the first anatomical landmark that was (type 1 m) or double CA (type 3) was seen in 24 (4.8%) and
looked for at the start of dissection. Depending on the appearance, 10 (2%) of patients respectively. Aberrant RHA in HCT (type 4)
the RS was classified into four types.11 The incidence and various was noted in 12 (2.4%) patients.
types of the sulcus in our study has been presented in Table 1. RS CVS was achieved in 463 patients (92.6%). It was complete in
407 patients (81.4%) in whom both CA and CD were displayed.
In five patients (1%) it was considered incomplete where the distal
Table 2 Cystic duct (CD) anatomy and variations (n = 500)
1/3 of the GB could not be completely lifted from the cystic plate.
In 51 (10.2%) patients the CA was divided first (artery first tech-
Type Description n % nique) to facilitate dissection of the HCT and identify the cystic
Normal Dissected length of the CD is 339 67.8 duct. Infundibular technique, though considered unsafe, had to be
2 cm-4 cm performed in one patient only in view of gross bowel distention
Wide CD requiring large (L) size Hemolok 71 14.2
making exposure of the HCT almost impossible. Fundus first
(Weck, nonabsorbable polymer
ligating clip), LT 400 ligaclip and/or subtotal cholecystectomy was performed in the remaining
(Ethicon endosurgery ltd) or suture 28 (5.6%) where CVS could not be achieved. Eight patients
ligation
(1.6%) were converted to open cholecystectomy due to difficult
Long Dissected length of the CD is >2 cm 30 6
Short Dissected length of the CD is <2 cm 07 1.4 anatomy. Additional findings noted in the GB bed (cystic plate)
Short & wide As above 22 4.4 were, dilated veins in six and cholecystohepatic duct in one
Long & wide As above 01 0.2
patient.
Sessile CD length not definable 01 0.2
NI CD not identifiable due to 29 5.8 There was no perioperative mortality. Two patients with subtotal
inflammation and/or fibrosis cholecystectomy had minor bile leak in the postoperative period
that subsided in the second week with conservative management.
Table 3 Classification of the cystic artery and incidences of various types, of stone/s in either CD or CBD. Long cystic duct was noted in 6%
based on their appearance during laparoscopic cholecystec- of our patients compared to 7%–12% in other reports.10,18 This dis-
tomy (n = 500)
crepancy can be due to the variation in the extent of CD dissected
Type Description n % during surgery. Short CD and sessile GB were found in 1.4%,
1 s—single CA superomedial to CD in the HCT 384 76.8 0.2% of patients respectively. Despite the low incidence, such cases
(Fig. 2a) pose real technical challenges during LC. We did not observe any
m—multiple arterial branches in the HCT due 24 4.8 case of CD joining right hepatic duct or sectoral ducts as has been
to early division of the CA (Fig. 2b)
2 Inferior CA, that is, artery arising infero lateral 40 8 reported in a series.10 We attribute this to our policy of conservative
that may run behind or cross the CD to yet adequate dissection of CD where the display of its insertion into
enter the HCT to supply the GB. (Fig. 3a–d) the CBD is not persisted with.
3 Double CA—Both the arteries appear to arise 10 02
at different planes and, unlike early division The cystic artery is considered the most variable structure in the
of CA, do not appear to converge on a hepatocystic triangle.7,9 Failure to identify the variations, with
single artery in the HCT. (Fig. 4) respect to its number and position, may result in inadvertent injury
4 Small CA arising from aberrant right hepatic 12 2.4
artery in the HCT. (Fig. 5) to the artery and bleeding. Attempt to control the bleeding may lead
NI CA not identifiable due to inflammation/ 30 06 to further injury to adjacent structures. An over-simplified classifi-
fibrosis/ multiple small branches cation was proposed that classified CA into three types – CA inside
Abbreviations: CA, cystic artery; CD, cystic duct; HCT, hepatocystic trian- or outside the Calot’s triangle or both.19 The classification
gle; GB, gallbladder. suggested by us is based on real-time dissection in a large number
of patients. Type 1, that is, single CA superomedial to the CD in
the HCT, was the commonest variant. Our observation in this
neither possible nor important to know the exact contents of the regard (76.8%) is similar to what has been reported in literature
sulcus though portal pedicle at times can be clearly identified in it. (72%–80%).7–9,20 The CA divides close to the GB surface into
The process of achieving CVS requires clear delineation of two superficial and deep branches that can be demonstrated with careful
structures namely CD and CA. Normal CD is around 2–4 cm long dissection though application of clips on the main trunk suffices for
and 2–3 mm in diameter. It can have variable course and insertion both. On the contrary, early division of the CA resulting in more
into the CBD.6,9 Dissection of CVS during LC requires isolation of than one arterial trunk (Type 1 m), found in 4.8% in the present
CD in the HCT and its junction with the GB infundibulum. It is not study, behaves like double CA that requires individual control.
important to trace the entire course of CD distally till it joins the Type 2 variant, 8% in our experience, known as inferior CA is seen
CBD. Such an attempt may even be hazardous.17 However, it is our in approximately 6%–10% of cases.8,10,19,20 This artery usually
practice to carefully dissect the CD distally as far as possible so that arises from gastroduodenal artery or common hepatic artery, runs
we do not leave behind a long stump with/without an unsuspected inferolateral to the CD to supply the GB.8 Though the artery in
stone inadvertently. Normal CD was clearly defined in 67.8% of most of its course lies outside the HCT, it may cross the CD anteri-
our patients which is comparable to 62.5%–87.8%.10,18 reported by orly or posteriorly to be identified in the HCT close to GB. Because
other authors. Wide cystic duct was the commonest abnormality of its position the artery can often be mistaken as CD till CVS is
found in our patients (normal length 14.2%, short 4.4%, and long completely established. Type-3, double CA was noted in 2% of our
0.2%). In nearly one fourth of patients this was due to the presence patients. The reported incidence of this variant in LC as well as
cadaveric studies ranges from 3% to 25%.5,7–9,19,20 Such wide vari-
ation in the incidence of double/multiple CA may be because of
cadaveric dissection, and/or mistakenly including deep and superfi-
cial branches from an early division of CA as double CA. In case
of double CA, the artery arising from RHA usually runs as deep
CA whereas the superficial branch can arise from any of the major
arteries in that region.21 Type-4, the short CA arising from RHA in
the HCT can be considered an anatomical trap. We found this vari-
ant in 2.4% in contrast to 3%–9.5% reported in literature.8,9,19 Pres-
ence of these CA variants re-emphasizes the need for careful
dissection of HCT to define its course. Alternatively, when a clear
dissection is not possible due to inflammation and/or fibrosis, a
safer alternative is to secure the CA lateral to the cystic LN on the
GB surface (artery first technique), thereby avoiding potential
injury to aberrant RHA. In the present series the CA was not identi-
fiable in 6%. This can be attributed to obscure anatomy, proper CA
replaced with multiple smaller branches or its absence.
The single most important step of a safe cholecystectomy
Fig. 5. Type 4: Small cystic artery (CA) arising from aberrant right hepatic entails achieving CVS after due dissection of HCT preceding
artery (RHA) which is the dominant artery in the hepatocystic triangle division of CA and CD.22 During this phase, it is important to be
aware of the aberrant anatomy so as to avoid any intraoperative 4. Bansal VK, Misra M, Agarwal AK et al. SELSI consensus statement
complication due to inadvertent injury to RHA or CBD.7,9 Simi- for safe cholecystectomy—prevention and management of bile duct
lar to the reported experience,2 CVS was achieved in more than injury—part B. Indian J. Surg. 2019; 83: 611–24. https://doi.org/10.
90% of our cases either by conventional or modified 1007/s12262-019-01994-1.
5. Hollinshead WH. Anatomy for Surgeons, Vol. 2. New York: Harper
(AF) dissection. When alternative dissection techniques (fundus
and Row, 1971; 353–8.
first and/or subtotal cholecystectomy) were adopted because of
6. Adkins RB, Chapman WC, Reddy VS. Embryology, anatomy, and sur-
inflammation and fibrosis, it was still possible to identify impor- gical applications of the extrahepatic biliary system. Surg. Clin. North
tant components of anatomy in most patients. We did not encoun- Am. 2000; 80: 363–79.
ter any major bile duct or vascular injury in our series is a 7. Bergamaschi R, Ignjatovic D. More than two structures in Calot’s trian-
testimony of the meticulous dissection following principles of gle: a post mortem study. Surg. Endosc. 2000; 14: 354–7.
safe laparoscopic cholecystectomy. 8. Andall RG, Matusz P, du Plessis M, Ward R, Tubbs RS, Loukas M.
The clinical anatomy of cystic artery variations: a review of over 9800
cases. Surg. Radiol. Anat. 2016; 38: 529–39.
Conclusion 9. Larobina M, Nottle PD. Extrahepatic biliary anatomy at laparoscopic
cholecystectomy: is aberrant anatomy important? ANZ J. Surg. 2005;
Wide variation in the anatomical structures is encountered during 75: 392–5.
the conduct of safe laparoscopic cholecystectomy. Awareness is 10. Singh K, Singh R, Kaur M. Clinical reappraisal of vasculobiliary anat-
paramount for safe dissection to avoid bilio-vascular injury. omy relevant to laparoscopic cholecystectomy. J. Minim. Access Surg.
2017; 13: 273–9.
11. Ibrarullah M, Sikora SS. Surgical anatomy relevant to cholecystectomy.
Author contributions In: Ibrarullah M, Sikora SS (eds). Safe Cholecystectomy: An Illustrated
Atlas. New York: CRC Press, Taylor & Francis, USA, 2022; 9–24.
Mohammad Ibrarullah: Conceptualization; data curation; 12. Gupta V, Jain G. The R4U planes for the zonal demarcation for safe
formal analysis; methodology; writing – review and editing. laparoscopic cholecystectomy. World J. Surg. 2021; 45: 1096–101.
Laxminarayan Mohanty: Conceptualization; data curation; formal 13. Hugh TB, Kelly MD, Mekisic A. Rouviere’s sulcus: a useful landmark
analysis; supervision; writing – original draft. Abhishek Mishra: in laparoscopic cholecystectomy. Br. J. Surg. 1997; 84: 1253–4.
Data curation; formal analysis; methodology; validation; writing – 14. Cheruiyot I, Nyaanga F, Kipkorir V et al. The prevalence of the
original draft. Ashirbad Panda: Data curation; formal analysis; Rouviere’s sulcus: a meta-analysis with implications for laparoscopic cho-
writing – original draft. Sadiq Sikora: Conceptualization; data lecystectomy. Clin. Anat. 2020; 34: 1–9. https://doi.org/10.1002/ca.23605.
15. Lazarus L, Luckrajh JS, Kinoo SM, Singh B. Anatomical parameters of
curation; formal analysis; writing – review and editing.
the Rouviere’s sulcus for laparoscopic cholecystectomy. Eur. J. Anat.
2018; 22: 389–95.
16. Dahmane R, Morjane A, Starc A. Anatomy and surgical relevance of
Conflict of interest statement Rouviere’s sulcus. Scientific World Journal 2013; 2013: 1–4. https://
None declared. doi.org/10.1155/2013/254287.
17. Strasberg SM, Callery MP, Soper NJ. Laparoscopic surgery of the bile
ducts. Gastrointest. Endosc. Clin. North Am. 1996; 6: 81–105.
18. Al Helli A, Al Taee M, Al Khafaji M. Laparoscopic surgical anatomy
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