Successful Laparoscopic Cholecystectomy in Moderate to Severe Acute Cholecystitis: Visual Explanation with Video File

Background

Laparoscopic cholecystectomy is now used worldwide due to its recognized and validated advantages [1]. Laparoscopic cholecystectomy has a rapid learning curve because techniques such as lymph node dissection and anastomotic reconstruction are not required during laparoscopic surgery [1,2]. The first case of laparoscopic cholecystectomy was reported in 1989 [3], which was followed by its use worldwide [4–7]. However, clinical studies have shown that the experience of the surgeon alone is not enough to ensure a successful outcome in laparoscopic cholecystectomy for acute cholecystitis [2]. Unexpected biliary injury is a terrible nightmare for any surgeons, and this iatrogenic complication is usually caused by anatomical mis-identification due to the assumption by the surgeon of the anatomical location of the cystic artery and the cystic duct, despite the visual field being altered by inflammation [1,2].

In recognition of the iatrogenic complications arising from poor visualization of key arterial and biliary structure during laparoscopic cholecystectomy for acute cholecystitis, in 1995, the concept of the ‘critical view of safety’ was proposed, which highlighted that the cystic artery and the cystic duct should be positively identified as they join the gallbladder [8]. Briefly, this protocol recommends that a tentative division of cystic structures should be completed at Calot’s triangle, which consists of the cystic duct, the common hepatic duct, and the cystic artery [8]. Inflammatory, fibrous, and fatty tissues are dissected, the structures of Calot’s triangle are dissected, the neck and body of the gallbladder are separately blunt-dissected from the liver bed, and as important structures become visible, key anatomic structures will only be cut when their identification is confirmed [8].

An ‘infundibular cystic duct’ may be hidden by inflammation in acute cholecystitis, leading the surgeon to wrongly identify the common bile duct or the common hepatic duct as the cystic duct [9]. Conclusive identification of the cystic structures is a key for successful laparoscopic cholecystectomy [2,8], and severity of acute cholecystitis is an important risk factor in anatomic misidentification [9]. Unless the identification of these key arterial and biliary structures are confirmed, iatrogenic surgical errors may occur due to the surgeon’s incorrect assumptions [2,8]. From the technical viewpoint, laparoscopic cholecystectomy may become difficult in patients who have extrinsic compression of the main biliary tree (e.g. Mirizzi syndrome), for example in patients with obstruction of the common hepatic duct due to an impacted gallstone in the cystic duct or Hartmann’s pouch (Mirizzi syndrome).

A case series is presented of seven patients who presented to our institution with moderate-to-severe acute cholecystitis and who underwent laparoscopic cholecystectomy using an established critical view of safety protocol and includes a visual description of the procedure with discussion of the technical approaches and pitfalls in these cases.

Case Report

This case series and the surgical approach was approved by the Institutional Review Board of Tenri Hospital according to the Declaration of Helsinki. The patients involved in this study provided written informed consent authorizing the use and disclosure of their anonymized health information and surgery. In all seven cases, surgical treatment was clinically indicated [10]. All surgical procedures were undertaken according to the current 2018 Tokyo Guidelines, of the Japanese Society of Hepato-Biliary-Pancreatic Surgery [11–13].

Seven patients are presented who underwent emergency laparoscopic cholecystectomy for moderate-to-severe acute cholecystitis. Clinical and demographic data were recorded and expressed as the mean ± standard deviation (SD) for the seven patients in this case series. The mean age was 63.0±13.0 years. There were five men and two women. The clinical diagnoses included five cases of severe or gangrenous cholecystitis and two cases of acute cholecystitis with moderate inflammation.

The laparoscopic cholecystectomy procedure, using the critical view of safety protocol, are described and illustrated in Figures 1–4), and the accompanying videos. The mean operative time and mean operative blood losses were 71.6±17.2 minutes and 36.9±15.0 ml, respectively. The mean operative time to complete the critical view of safety protocol was 54.0±17.4 minutes. None of the seven cases underwent conversion to open surgery. The mean postoperative duration to adequate ambulation and normal diet were 0.7±0.5 days and 1.0±0.6 days, respectively. Patients discharged at a mean of 3.9±0.9 days following emergency laparoscopic cholecystectomy. In all seven cases, the postoperative course was uneventful, and postoperative complications categorized as ≥Grade II according to the Clavien-Dindo classification were not observed [14]. None of the seven cases who underwent laparoscopic cholecystectomy had biliary injury, because the critical view of safety protocol was followed [1].

The surgical protocol used in this case series, for improved patient outcome following laparoscopic cholecystectomy, has been previously documented in detail [1]. Based on our protocol [1]. Figures 1–4 show the schema that visually explain the surgical protocol, which were drawn for this report by the co-author Tomohide Hori.

Briefly, the key points in the surgical procedures undertaken in this case series can be summarized as follows. The U-shaped line at the hepatic hilum was identified, and the common hepatic duct was identified in the base of this line, thereby avoiding unexpected injury of the common hepatic duct and right anterior biliary duct. The line of surgical dissection was undertaken close to the common hepatic duct, the common bile duct, and the gallbladder. Using an adequate overhead view, the angle between the cystic duct and the common hepatic duct was widely dilated, to prevent unexpected biliary injuries due to the hidden or parallel cystic ducts. Therefore, in this protocol, alignment of the components of the biliary tree should be maximized to avoid any tenting of the common bile duct and the common hepatic duct. Using an adequate lower view, the S-shaped curve from Hartmann’s pouch and the gall-bladder infundibulum to the infundibulum-cystic duct junction were confirmed, so that the infundibulum-cystic duct junction and the cystic duct were dissected according to an inverted V-shaped line. Using an adequate rightward and upward view, Rouviere’s sulcus should be intentionally recognized to avoid biliary injury, especially to avoid unexpected injury to the common bile duct and right posterior biliary duct. The gallbladder was blunt-dissected as close to the gallbladder wall as possible, and fatty tissue of Rouviere’s sulcus was dissected away. The gallbladder was completely blunt-dissected from the liver bed. Finally, all cystic structures entering into the gallbladder were ‘definitively’ and ‘positively’ dissected, and the critical view of safety protocol for laparoscopic cholecystectomy was completed (Figures 1–4). A relevant video for each figure is included as supporting information because the actual procedures should be shown.

Discussion

In cases of moderate-to-severe acute cholecystitis, inflammation can result in changes that may obscure the usual anatomical location or appearance of the vascular and biliary structures, including the cystic artery and the cystic duct. The ‘infundibular cystic duct,’ or ‘the hidden cystic duct syndrome’ can occur in acute cholecystitis as the cystic duct that may be hidden by inflammation, leading the surgeon to wrongly identify the common bile duct as the cystic duct [9].

Also, Hartman’s pouch and the gallbladder neck can be unexpectedly located beneath the common hepatic duct. These pitfalls can mislead the surgeon into assuming that the common bile duct or the common hepatic duct is the cystic duct [9]. Reports of ambiguity during laparoscopic cholecystectomy, such as a ‘second cystic duct,’ ‘accessory duct,’ and ‘dual common hepatic duct,’ demonstrate the way in which misidentification of the cystic duct can occur [8]. We should never forget that subtotal cholecystectomy for difficult case is a terrible idea [15], though a remnant of the cystic duct is considered as permissive [1]. The ‘L-hook technique’ has been shown to have practical use [1,8]. It is important to make the surgical procedure of laparoscopic cholecystectomy as safe and free from complications as possible, as subtotal cholecystectomy, which that may be required following these complications, can be a difficult procedure that also has potential complication [15].

During laparoscopic cholecystectomy, technical experience, surgical skill, and anatomical knowledge do not necessarily prevent iatrogenic biliary injury. The anatomical assumptions that may be made during laparoscopic cholecystectomy are the main causes of unexpected biliary injuries [1,2,8].

Conclusions

A case series of seven patients who presented with moderate-to-severe acute cholecystitis and who underwent laparoscopic cholecystectomy, showed good postoperative outcome without surgical complications, using a using a critical view of safety protocol. Safe laparoscopic cholecystectomy should be the priority, even in acute cholecystitis. The authors hope that this presentation of a cases series that includes a detailed description of our surgical protocol for successful laparoscopic cholecystectomy will provide benefit for patients who present with moderate-to-severe acute cholecystitis.