Anatomic Variation of the Cystic Artery: New Findings and Potential Implications

Aberrant anatomy in the context of the critical view of safety

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.

Surgical anatomy of the cystic artery: A systematic review with meta-analysis

BACKGROUND

The current evidence-based systematic review with meta-analysis presents a detailed overview of the cystic artery (CA) surgical anatomy, including its origin, number, topography, and morphometry. Moreover, the surgical implications of these variants are further discussed.

METHODS

According to the Evidence-Based Anatomy Workgroup and PRISMA 2020 guidelines, the systematic review was performed using four online databases. The Anatomical Quality Assurance Tool was used to evaluate the risk of bias. Meta-analysis was performed with the R programming software. The pooled prevalence and pooled mean of different CA parameters were calculated.

RESULTS

The CA most commonly originated from the right hepatic artery (a pooled prevalence of 85.75 %). Other described origins (in order of frequency) were the aberrant right hepatic artery, the common hepatic, the left hepatic, the gastroduodenal, the superior mesenteric, and the middle hepatic arteries. The CA was single in 88.59 %, while it can be identified as double, triple, or absent. Most commonly, it was located inside the cystohepatic triangle in 83.83 %. Most commonly, it was superomedially to the cystic duct (77.80 %) and posteriorly to the common hepatic duct (35.08 %). The CA pooled mean length was 21.34 mm, and its diameter was more commonly over 1 mm.

CONCLUSION

The CA surgical anatomy is paramount when operating on the gallbladder. The CA's altered anatomy and adjacent area could lead to confusion, iatrogenic injury, and prolonged surgical time. The CA depicts high morphological variability; therefore, surgeons should consider the typical anatomy and possible (usual and unusual) variants.

Anatomical Schemata Revealed by the Critical View of Safety Approach: A Proposal of the Hellenic Task Force on the Typology of Safe Laparoscopic Cholecystectomy (HETALCHO)

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.

Investigating precise control pathway for haemostatic clip usage in laparoscopic cholecystectomy based on patient clinical variations: an exploratory retrospective observational study

OBJECTIVES

To explore a precise control pathway based on patient clinical variations for haemostatic clip usage in laparoscopic cholecystectomy (LC) through on-site research data from a teaching hospital. Specifically, the study aimed to: (1) to calculate the optimal haemostatic clip consumption in LC based on diagnostic grouping and surgical combinations, and (2) to provide evidence for cost containment of high-value medical consumables used in LC.

DESIGN

Retrospective observational study.

SETTING

Hospital in southwest China.

PARTICIPANTS

The inclusion criteria were set as inpatients whose medical records included International Classification of Diseases codes 1-3 with code 51.2300 (corresponding to LC surgery) and who were discharged on medical advice. A dataset containing 1001 patients without any haematological diagnoses was collected.

PRIMARY AND SECONDARY OUTCOME MEASURES

Two ordered multinomial logit models were established to identify factors affecting haemostatic clip use in LC. Two-step clustering was used to form subgroups. The premodel included preoperative variables (acute cholecystitis and scarring/fibrotic atrophy), while the full model added intraoperative variables (anatomical variation and severe adhesions). Both models met application prerequisites.

RESULTS

Key factors influencing haemostatic clip usage were identified, including acute cholecystitis, scarring/fibrotic atrophy, anatomical variation and severe adhesions. Consumption references for haemostatic clips were established for LC patients with good prognoses on discharge. The ordered multinomial logit model revealed that acute cholecystitis decreased the odds of using four or more clips (p<0.001), while anatomical variation, scarring/fibrotic atrophy and severe adhesions increased the odds (p<0.001 for all). The model suggested using no more than three clips in 17.30% of cases, precisely four clips in 81.72% of cases and five or more clips in 0.98% of cases, depending on the co-occurring factors. Model-predicted clip usage was consistent with actual usage (consistency=0.56).

CONCLUSIONS

This study provides a framework for evidence-based consumable management in LC, demonstrating the potential for extrapolation to other consumables and surgical combinations. Continuous monitoring and timely adjustment will be imperative as medical products and practices evolve.

Shoeshine maneuver for cystic duct dissection: a simple technique to make Calot-triangle dissection smooth

PURPOSE

Laparoscopic cholecystectomy, introduced in 1985 by Prof. Dr. Erich Mühe, has become the gold standard for treating chronic symptomatic calculous cholecystopathy and acute cholecystitis, with an estimated 750,000 procedures performed annually in the United States of America. The risk of iatrogenic bile duct injury persists, ranging from 0.2 to 1.3%. Risk factors include male gender, obesity, acute cholecystitis, previous hepatobiliary surgery, and anatomical variations in Calot's triangle. Strategies to mitigate bile duct injury include the Critical View of Safety and fundus-first dissection, along with intraoperative cholangiography and alternative approaches like subtotal cholecystectomy.

METHODS

This paper introduces the shoeshine technique, a maneuver designed to achieve atraumatic exposure of anatomical structures, local hemostatic control, and ease of infundibulum mobilization. This technique involves the use of a blunt dissection tool and gauze to create traction and enhance visibility in Calot's triangle, particularly beneficial in cases of severe inflammation. Steps include using the critical view of safety and Rouviere's sulcus line for orientation, followed by careful dissection and traction with gauze to maintain stability and reduce the risk of instrument slippage.

RESULTS

The technique, routinely used by the authors in over 2000 cases, has shown to enhance patient safety and reduce bile duct injury risks.

CONCLUSION

The shoeshine technique represents a simple and easy way to apply maneuver that can help surgeon during laparoscopic cholecystectomies exposing the hepatocystic area and promote blunt dissection.

Comparison of the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy

OBJECTIVE

To compare the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy (DLC).

METHODS

From June 2021 to August 2022, data from 100 patients undergoing DLC at Nanjing Hospital of Traditional Chinese Medicine were analyzed retrospectively. Patients were divided into two groups: the experimental group (LC with the ampulla-guided realignment) and the control group (conventional LC with triangular gallbladder anatomy), with 50 patients per group. The intraoperative blood loss, operation time, postoperative drainage tube indwelling time, hospitalization time, bile duct injury rate, operation conversion rate, and incidence of postoperative complications were recorded and compared between the two groups. The pain response and daily activities of the patients in the two groups were evaluated 48 h after the operation.

RESULTS

The amount of intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, operation conversion rate, pain degree at 24 and 48 h after operation, bile duct injury incidence, and total postoperative complication rate were shorter or lower in the experimental group than those in the control group (p < 0.05). The Barthel index scores of both groups were higher 48 h after the operation than before the operation, and the experimental group was higher than the control group (p < 0.05).

CONCLUSION

The ampulla-guided alignment in DLC surgery was more beneficial in promoting postoperative recovery, reducing postoperative pain response, reducing the incidence of postoperative complications, and reducing bile duct injury.