The inferior boundary of dissection as a novel landmark for safe laparoscopic cholecystectomy

Anatomical insights into Rouviere's Sulcus through the Glissonean approach in minimally invasive right-sided sepatectomy

BACKGROUND

Understanding the liver anatomy, particularly the Rouviere sulcus (RS), is crucial for safely performing cholecystectomy and hepatectomy. As surgical interest in right-sided hepatectomies using the Glissonean pedicle approach has increased, a thorough understanding of the RS anatomy is becoming increasingly important. This study aimed to investigate the presence and anatomical contents of the RS during right-sided hepatectomy and to develop a preoperative assessment method to improve surgical safety and precision.

METHODS

Patients who underwent laparoscopic or robotic right-sided hepatectomy with RS dissection were included in the study. The RS was categorized into open and closed types, and its contents were examined to identify the presence of Glissonean pedicles. The findings were compared with simulations generated from 3-dimensional reconstruction imaging for further analysis.

RESULTS

Of the 83 patients, 62 (74.7%) had open-type RS, and 21 (25.3%) had closed-type RS. Among the open-type RS cases, 38 patients (61.3%) involved the right posterior Glissonean pedicle within the RS, whereas 19 patients (30.7%) involved segment 6 Glissonean pedicle. Preoperative imaging revealed that when the right posterior Glissonean pedicle did not form a common trunk with segments 6 and 7, the Glissonean pedicle of segment 6 was located within the RS. The variation observed in 5 cases (8.1%) with the right main Glissonean pedicle in the RS was significant and should be carefully considered during surgery.

CONCLUSION

A thorough understanding of the RS anatomy is essential for safe and precise right-sided hepatectomy. Our findings emphasize the variability of RS, particularly concerning the presence of different Glissonean pedicles, including the right posterior segment 6 and, in rare cases, the right main Glissonean pedicle. Our findings highlight the necessity for individualized preoperative imaging and careful consideration of anatomical variations to minimize complications during right-sided hepatectomy.

Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital

BACKGROUND

We have developed an algorithmic approach to laparoscopic cholecystectomy, including subtotal cholecystectomy, as a bailout strategy when the Critical View of Safety cannot be safely achieved due to significant inflammation and fibrosis of the hepatocystic triangle.

METHODS

This is a retrospective cohort study comparing postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy at St. Joseph's Health Centre from May 2016 to July 2021, as well as against a historical cohort. We further stratified laparoscopic subtotal cholecystectomy cases based on fenestrating or reconstituting subtype.

RESULTS

The cohort included a total of 105 patients who underwent laparoscopic cholecystectomy and 31 patients who underwent laparoscopic subtotal cholecystectomy. Bile leaks (25.8% vs 1.0%, relative risk 3.5, 95% confidence interval 3.5-208.4) were more common in the laparoscopic subtotal cholecystectomy group. Postoperative endoscopic retrograde cholangiopancreatography (22.6% vs 3.8%, relative risk 5.9, 95% confidence interval 1.9-18.9) and biliary stent insertion (19.4% vs 1.0%, relative risk 20.3, 95% confidence interval 2.5-162.5) were also more common in the laparoscopic subtotal cholecystectomy group. Bile leaks in laparoscopic subtotal cholecystectomy were only documented in the fenestration subtype, most of which were successfully managed with endoscopic retrograde cholangiopancreatography and biliary stenting. Compared to our previous study of laparoscopic cholecystectomy and subtotal cholecystectomy for severe cholecystitis between 2010 and 2016, there has been a decrease in postoperative laparoscopic cholecystectomy complications, subtotal cholecystectomy cases, and no bile duct injuries.

CONCLUSION

Following our algorithmic approach to safe laparoscopic cholecystectomy has helped to prevent bile duct injury. Laparoscopic cholecystectomy remains the gold standard for the management of severe cholecystitis; however, in extreme cases, laparoscopic subtotal cholecystectomy is a safe bailout strategy with manageable morbidity.

Clinical Efficacy of Laparoscopic Cholecystectomy via Cystic Plate Approach for Gallstone Patients with Chronic Cholecystitis

Introduction: Chronic cholecystitis has evolved into one of the digestive system diseases that negatively affect the quality of life of patients. This study was conducted to explore the clinical efficacy of laparoscopic cholecystectomy via cystic plate approach for the treatment of gallstones with chronic cholecystitis. Materials and Methods: Totally 184 gallstone patients with chronic cholecystitis who underwent laparoscopic cholecystectomy in The First People's Hospital of Wuhu from January 2021 to October 2022 were randomly divided into a control group (n = 92) and an observation group (n = 92). In the observation group and control group, the gallbladder was removed using the cystic plate approach and traditional approach, respectively. Surgical indicators and complications of patients were compared. Serum levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) were measured by enzyme-linked immunosorbent assay. The quality of life of patients was assessed using the SF-36 scale. Results: The recovery time of gastrointestinal function, intraoperative blood loss, and postoperative drainage volume in the observation group were significantly lower than those in the control group (P < .05). At 24 hours after surgery, the serum levels of IL-6, TNF-α, and CRP in the observation group were much lower than those in the control group (P < .05). Three months after surgery, the observation group showed a much higher quality of life score than the control group (P < .05). Conclusion: Laparoscopic cholecystectomy via cystic plate approach can effectively treat chronic gallstones with chronic cholecystitis. It shortened the recovery time of gastrointestinal function, reduced postoperative inflammation, and improved the quality of life.

Fat clearance in the hepatocystic triangle during laparoscopic cholecystectomy: Fact or fad? An NIRF-based study

INTRODUCTION

At present, the pre- and postdissection regions during laparoscopic cholecystectomy (LC) are uniformly described by the term "hepatocystic triangle" (HCT). It is unclear whether a distinction needs to be made. An observational study was undertaken to evaluate the predissection hepatocystic region (pre-HCR) and the postdissection hepatocystic region (post-HCR). Also, the dissection-related changes to the contents of the pre-HCR ("proper HCT") were evaluated.

METHODS

A retrospective review of a prospectively maintained database was done. The operative videos of patients who underwent fluorescence-guided surgery from December 2021 to February 2022 were reviewed. Patients with gallstone disease without complications (GSD) were included in the study. Exclusion criteria were acute cholecystitis, choledocholithiasis, biliary pancreatitis, biliary fistulas, and gallbladder wall thickening of ≥3 mm on ultrasonography.

RESULTS

Thirteen patients underwent LC for GSD using standard dissection methods. The boundaries of the pre-HCR were identified before dissection in all patients. The dissection resulted in a quadrangular space lateral to the "proper HCT" in all. The post-HCR contained the undissected "proper-HCT" and the quadrangular space in all. The post-HCR area was 4.4 times that of the pre-HCR (3.2-13.1). The peritoneum over the "proper HCT" was unbreached in all patients, and the target structures were delineated outside of it. A critical view of safety (CVS) was demonstrated outside of the "proper HCT" in all patients.

CONCLUSION

During near-infrared fluorescence-guided LC for GSD, there is no fat clearance in the "HCT." The hepatocystic region before and at the conclusion were distinctly different. The uniform usage of the term "HCT" does not convey this change.

Thinking Your Way Through a Difficult Laparoscopic Cholecystectomy: Technique for High-Quality Subtotal Cholecystectomy

Laparoscopic subtotal cholecystectomy (LSC) is a bailout strategy to prevent bile duct injury in difficult gallbladder cases. It is associated with acceptable morbidity that is readily managed with postoperative interventions. Here we share our techniques for LSC. We begin with landmarking, which includes the line of safety, a theoretical line the sulcus of Rouvière and the junction of the cystic and hilar plates. If the fundus can be grasped, then the gallbladder is dissected off the cystic plate using the top-around approach. The gallbladder is then amputated, creating a short cuff of proximal gallbladder. This cuff can be left patent (2A) or cinched close with an ENDOLOOP (Ethicon) if it is small, ideally less than 1 cm (1A). If the fundus cannot be grasped, then an inverted T incision is made on the anterior gallbladder wall. The longitudinal incision is extended toward the fundus, and the transverse incision is extended superiorly along the cystic plate edge. Two "bunny ears" are developed and ultimately resected to excise the anterior gallbladder wall at an oblique angle while leaving the posterior wall intact (2B). If the remaining cuff is small, then it can be sutured closed against the gallbladder back wall (1B). In the setting of extensive bowel adhesion to the anterior gallbladder, we perform a fundectomy, from which we extend two incisions along the cystic plate to open the gallbladder like a clamshell. Our paper describes and illustrates our St Joseph's Health Centre institutional LSC approach and subtype classification (1A, 1B, 2A, and 2B).

Use of prospective video analysis to understand the impact of technical difficulty on operative process during laparoscopic cholecystectomy

BACKGROUND

An understanding of the impact of operative difficulty on operative process in laparoscopic cholecystectomy is lacking. The aim of the present study was to prospectively analyse digitally recorded laparoscopic cholecystectomy to assess the impact of operative technical difficulty on operative process.

METHODS

Video of laparoscopic cholecystectomy procedures performed at Christchurch Hospital, NZ and North Shore Private Hospital, Sydney Australia were prospectively recorded. Using a framework derived from a previously published standard process video was annotated using a standardized template and stratified by operative grade to evaluate the impact of grade on operative process.

RESULTS

317 patients had their laparoscopic cholecystectomy operations prospectively recorded. Seventy one percent of these videos (n = 225) were annotated. Single ICC of operative grade was 0.760 (0.663-0.842 p < 0.010). Median operative time, rate of operative errors significantly increased and rate of CVS decreased with increasing operative grade. Significant differences in operative anatomy, operative process and instrumentation were seen with increasing grade.

CONCLUSION

Operative technical difficulty is accurately predicted by operative grade and this impacts on operative process with significant implications for both surgeons and patients. Consequently operative grade should be documented routinely as part of a culture of safe laparoscopic cholecystectomy.

[Measures for preventing bile duct injuries during difficult cholecystectomies-Bail-out procedures]

BACKGROUND

Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon.

OBJECTIVE

Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy?

RESULTS

The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform a regular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary.

CONCLUSION

Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation.

Morphology of the sulcus of the caudate process (Rouviere's sulcus) in a Greek population and a systematic review with meta-analysis

The purpose of this study was to determine the prevalence and to investigate the morphology of the sulcus of the caudate process in a Greek population, along with a systematic review and meta-analysis of the literature. Overall, 103 consecutive patients undergoing laparoscopic cholecystectomy were included in the analysis. The sulcus was present in 91% and three morphological variants were identified (groove 69%, slit 21% and scar 10%). The sulcus had a horizontal course in 90% of patients and a mean length of 25 ± 13 mm. The meta-analysis included 27 surgical and 11 cadaveric studies with 6661 cases in total. The pooled prevalence of the sulcus was 80% and did not differ significantly among various geographical regions. Concerning sulcus subtypes, the binary "open/fused" classification was used to unify the heterogeneous data. The "open" type was more frequent than the "fused" (64.5% vs 35.5%). A horizontal course was observed in 53.5% and an oblique in 45.7%. The sulcus contained the right portal pedicle in 38%, the right posterior portal pedicle in 37%, and the right posteroinferior pedicle in 23.5%. In conclusion, the sulcus of the caudate process is a very helpful anatomical landmark in hepatectomy and laparoscopic cholecystectomy and can be identified in the majority of patients. However, various classifications for the morphological variants and diverse terminology cause discrepancy in the literature and create the need for a single classification system. The proposed 3-tier classification (groove, slit, scar) is simple and easy to remember and avoids ambiguous nomenclature.