Anatomy relevant to cholecystectomy

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.

Rouvière's Sulcus as a Landmark for a Safe Laparoscopic Cholecystectomy: An Interim Analysis of a Multicenter Cross-sectional Study on the Prevalence and Morphologic Type of Rouvière's Sulcus in the Italian Population

BACKGROUND

Laparoscopic cholecystectomy is the gold standard in the treatment of symptomatic gallstones. The large number of gallbladders removed every year is not fully consistent with the excessively high incidence of iatrogenic bile duct injury (IBDI). Several strategies have been suggested to reduce this risk. Among them, the use of extra biliary anatomic structures, such as the Rouvière's sulcus, as a landmark to guide the surgeon during dissection has been proposed as a means to prevent IBDI. The main aim of the present paper is the evaluation of the prevalence of Rouvière's sulcus (RS) and its anatomic variants in a given population.

MATERIALS AND METHODS

This observational, cross-sectional, and multicenter study has been conducted at the Department of Digestive and Emergency Surgery of the "Azienda Ospedaliera Santa Maria," Terni (Italy), at the Department of Surgical Sciences of the "Azienda Ospedaliera Perugia," Perugia (Italy) and at the Department of Emergency and Trauma Surgery of the "Policlinico Umberto I," Rome (Italy). Intraoperative images of 111 patients undergoing laparoscopic cholecystectomy were analyzed to identify the presence and type of RS, according to the Singh-Prasad classification and the Dahmane classification.

RESULTS

RS was present in 93 (83.8%) patients. Singh-Prasad type 1A is present in 48.4% of patients, type 1B in 25.8%, type 2 in 12.9% and type 3 in 12.9%. Dahmane's open type is present in 48.4% of patients and fused type in 51.6%.

CONCLUSION

Due to its high prevalence, RS can be used as an anatomic landmark and probably reduces the incidence of IBDI during laparoscopic cholecystectomy.

Post-operative complications of cholecystectomy: what the radiologist needs to know

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

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.

Biliary Anatomy 2.0 Quiz: Test Your Knowledge

Anatomy has remained an interest of physicians throughout the ages. The biliary tract spans from the liver to the hepatoduodenal mesentery, pancreas, and into the duodenum. Therefore, it is important for not only hepatobiliary surgeons but also general gastrointestinal surgeons, gastroenterologists, radiologists, and pathologists to be familiar with biliary anatomy and its variants. While surgery for hilar cholangiocarcinoma is one of the most challenging procedures, cholecystectomy is one of the most common procedures done from the beginning of surgical training. We hope that by answering the following questions, you will gain a comprehensive understanding of biliary anatomy and a greater appreciation for it.

Moynihan's hump of the right hepatic artery in Calot's triangle: a systematic review and meta-analysis of its incidence and surgical importance

INTRODUCTION

A rare variation known as "Moynihan's or caterpillar hump" of the right hepatic artery raises the danger of vascular and biliary injuries during hepatobiliary surgery. This research intends to carefully record every case (i.e., patients undergoing laparoscopic cholecystectomy or cadaver dissections) where the right hepatic artery received a caterpillar hump.

METHODS

The literature search was conducted with the medical subject headings (MeSH) and EMTREE (subject headings unique to Embase) keywords. The keywords with Boolean operators (OR, AND, and NOT) were used to create search strings in all possible combinations to retrieve bibliographic data. Two authors independently performed a risk of bias assessment and data extraction. The random effects model was used to conduct a meta-analysis.

RESULTS

Thirty studies with a total of 8418 subjects reported that Moynihan's hump was present in 3.81% of them, with a predictive interval of 0.88-16.45%. The incidence of the hump was 3.1% in surgical studies (7496 subjects) and 7.22% (95% CI 4.7-10.93%) in cadaveric data (625 cadavers). Only ten studies addressed the relationship between the caterpillar hump and the common bile duct.

CONCLUSION

A patient with an unusually "small cystic artery" or "large right hepatic artery" is likely to have a "caterpillar hump". The caterpillar's hump of the right hepatic artery is subject to rare anatomical variations in its course that increase the risk of incorrect vessel ligation or injury during laparoscopic cholecystectomy.

Learning curve for the surgical time of laparoscopic cholecystectomy performed by surgical trainees using the three-port method: how many cases are needed for stabilization?

BACKGROUND

The assessment of laparoscopic cholecystectomy (LC) skills using operating times has not been well reported. We examined the total and partial operating times for LC procedures performed by surgical trainees to determine the required number of surgeries until the surgical time stabilizes.

METHODS

We reviewed the video records of 514 consecutive LCs using the three-port method, performed by 16 surgical trainees. The total and partial surgical times were calculated and correlated to the surgeons' experience.

RESULTS

The median total surgical time for a trainee's first LC was 112 (range 71-226) minutes. It reduced rapidly after the first 20 LCs and plateaued to its minimum after approximately 60 cases. A statistically significant time decrease was observed between the first 10 (median, range 112, 46-252 min) and the next 50-59 cases (64, 34-198 min), but not between the 50-59 and the subsequent 100-109 cases (71, 33-127 min). The total times taken by trainees who had performed > 50 operations were not significantly different from those taken by instructors during the study period. Surgery for 125 patients with acute cholecystitis took a significantly longer time (median 99 vs. 74 min with non-acute cholecystitis); however, the abovementioned time reduction findings showed similar results regardless of the patient's acute inflammation status. The partial operating times around the cervical/cystic duct and gallbladder bed reduced uniformly between the first 10 and the following 50-59 cases. Although time variations in total and cervical/cystic duct operating times were not correlated to the surgical experience, time fluctuation of gallbladder bed procedures reduced after 60 cases.

CONCLUSION

The time required to perform an LC was inversely correlated with the experience of surgical trainees and halved after the first 60 cases. The surgical experience required for LC time stabilization is approximately 60 cases.

Cystic duct cyst in adults: a systematic review of the sixth entity

Over the past two decades, there have been an increasing number of reports describing a sixth type of choledochal cyst (cystic duct cyst) in adults that was not included in Todani's classification. This sixth entity has not yet been systematically reviewed in the literature. We therefore explored this condition in adults from the perspective of the clinical presentation, diagnosis and treatment through a systematic review of the evidence. The final analysis included 33 reported cases, with 55% of them reported in Asia. The mean age was 39.3 years old, with a female-to-male ratio of 1.5:1. Magnetic resonance cholangiopancreatography was accurate in establishing the diagnosis in 69% of cases. Where reported, standard laparoscopic/open cholecystectomy was performed in about 74% of patients, while around 25% of them needed extensive surgery. Associated malignancy was reported in 6.1% of cases, while 28% of patients had co-existent gallstone-related disease. No significant post-operative morbidity or mortality was reported. In this era of emergency laparoscopic cholecystectomy, surgeons should be aware of this rare condition, with the particular understanding that it is associated with gallstone-related disease in a significant number of reported cases.

Moynihan's Lump as an unusual variant of right hepatic artery during a laparoscopic cholecystectomy approach. A case report

Introduction and importance

One of the most important measures during the cholecystectomy procedure is based on a “Culture for Safe Cholecystectomy (CSC)”. Vascular injury reports an open surgery conversion rate of 0 to 1.9% and a mortality of less than 0.02%. The caterpillar or Moynihan's hump configuration is characterized by a tortuous right hepatic artery (RHA) running proximal and/or parallel to the cystic duct and predisposes to a small and/or short cystic artery (CA).

Case presentation

A 65-year-old woman with no relevant clinical history underwent a laparoscopic cholecystectomy (LC) for cholelithiasis; during the procedure a caterpillar or Moynihan's hump was identified.

Clinical discussion

Anatomical variations represent 20-50% of all cases; therefore, CVS is required. The incidence of caterpillar or Moynihan's hump varies between 1% and 13% of all cases. To date, the scientific literature on this topic is limited. The most accepted etiology is related to embryological formation.

Conclusion

Biliary and arterial variations are more frequent than we think, so an anatomical knowledge, CSC and CVS represent a fundamental rule, increasing the safety of the surgical procedure.

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This is a reminder of how variant the anatomy of the biliary tree can be.

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Anatomical variations could increase the risk of inadvertent injury during LC.

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The certainty of a safe cholecystectomy is of great importance.

Cholecystectomy, porta hepatis stripping, and omental bursectomy

As ovarian cancer commonly involves the visceral organs without boundary, more aggressive procedures are adopted during cytoreductive surgery. One of the most difficult aspect of the operation involves the procedure for the gall bladder, porta hepatis, and omental bursa. As the upper abdominal surgical field is not familiar to the gynecologic surgeon, and the vital organs or vessels are densely positioned, these procedures can be challenging for achieving the optimal cytoreductive surgery. The surgical approaches for advanced ovarian cancer that are required in the upper abdomen have evolved with the progress in surgical techniques. This article will discuss the surgical approach by focusing on cholecystectomy, porta hepatis debulking, and omental bursectomy, as well as the regional anatomy in patients with advanced ovarian cancer.

Posterior infundibular dissection: safety first in laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC.

Methods

In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury.

Results

Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries.

Conclusion

Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.

Supplementary information

The online version of this article (doi:10.1007/s00464-020-08281-1) contains supplementary material, which is available to authorized users.

Cystic Lymph Node Identification Is More Reliable Than Critical View of Safety in Difficult Cholecystectomies

BACKGROUND

The cystic lymph node (CLN) represents an anatomic safety marker and a surrogate marker of technique during laparoscopic cholecystectomy (LC). We aim to demonstrate the value of CLN in comparison to the critical view of safety (CVS) and study the effects of increasing difficulty on the 2 approaches.

METHODS

A prospective study of consecutive LC was conducted. Patient demographics, type of admission, clinical presentation, operative difficulty grade, visualization of CLN, identification of CVS, operative time, and complications were recorded and analyzed.

RESULTS

Of 393 LCs, half of the admissions were emergencies. Thirty-four percent had obstructive jaundice or acute cholecystitis. The CLN was visually identified in 81.7% with a small difference between operative difficulty grades 1 to 3 versus 4 to 5. Although CVS was unachievable in 62 patients, 43 (69.4%) still had an identifiable CLN. The median operating time was 68 minutes with 1 mortality but no conversions or intraoperative complications.

CONCLUSIONS

Identifying the CLN during LC could compliment the CVS in avoiding major ductal injury. Dissecting lateral to the CLN to commence the process of displaying the cystic pedicle structures may be a strategy in safely achieving the CVS. During the more difficult LC where displaying the CVS is impossible, the CLN may be the key anatomic landmark.

Hartmann's Pouch Stones and Laparoscopic Cholecystectomy: The Challenges and the Solutions

Background & Objective:

Hartmann's pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syndrome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS.

Methods:

A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients' demographics, clinical presentation, intra-operative findings, and postoperative outcomes were compared.

Results:

Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute cholecystitis (27.9% vs 5.9%, P = .000) and more patients underwent emergency LC (50.7% vs 41.5%, P = .000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% P = .000, 30.9% vs 3.7% P = .000, 1.8% vs 0.9% P = .000, respectively). There was no significant difference in the open conversion rate or complications.

Conclusion:

HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ appropriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall bladder, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.

Gallbladder Carcinoma and Its Differential Diagnosis at MRI: What Radiologists Should Know

Gallbladder carcinoma is the most common cancer of the biliary system. It is challenging to diagnose because patients are often asymptomatic or present with nonspecific symptoms that mimic common benign diseases. Surgical excision is the only curative therapy and is best accomplished at early non-locally advanced stages. Unfortunately, gallbladder cancer often manifests at late locally advanced stages, precluding cure. Early tumors are often incidentally detected at imaging or at cholecystectomy performed for another indication. Typical imaging features of localized disease include asymmetric gallbladder wall thickening, polyps larger than 1.0 cm, and a solid mass replacing the gallbladder lumen. Advanced tumors are often infiltrative and can be confusing at CT and MRI owing to their large size. Determination of the origin of the lesion is paramount to narrow the differential diagnosis but is often challenging. It is important to identify gallbladder cancer and distinguish it from other benign and malignant hepatobiliary processes. Since surgical resection is the only curative treatment option, radiologist understanding and interpretation of pathways of nodal and infiltrative tumor spread can direct surgery or preclude patients who may not benefit from surgery. While both CT and MRI are effective, MRI provides superior soft-tissue characterization of the gallbladder and biliary tree and is a useful imaging tool for diagnosis, staging, and evaluation of treatment response. ^©RSNA, 2020.

Method for adequate macroscopic gallbladder examination after cholecystectomy

BACKGROUND AND AIMS

There is no clear guideline nor protocol for macroscopic examination of the gallbladder, leaving surgeons extemporaneous in regard of gallbladder examination in selective histopathologic policy. The purpose of this article is to describe a surgical approach for adequate macroscopic inspection of the gallbladder.

MATERIALS AND METHODS

The described practical method was developed in collaboration between surgeons and pathologists. This method was introduced in 2011 and implemented in 2012. We retrospectively reviewed the number of cholecystectomies and number of histopathologic examinations between 2006 and 2017, using our own patient database. We used the Netherlands Cancer Registry (NCR) to examine the incidence of gallbladder cancer patients before and after implementation of the selective policy in our hospital. In addition to the method, we depict several frequent macroscopic abnormalities in order to provide some examples for surgical colleagues.

RESULTS

Since implementation of the selective policy, 2271 surgical macroscopic gallbladder examinations were performed. As a result, we observed a significant decrease from 83% in 2012 to 38% in 2017, in histopathologic examination of the gallbladder following cholecystectomy. We observed a stable trend of gallbladder carcinoma in the same period (0.17%, n = 4 during 2006-2011 and 0.26%, n = 6 during 2012-2017).

CONCLUSION

A simple, valid and easy method is described for future macroscopic analysis by the surgeon following a cholecystectomy.

Importance of Rouviere's sulcus in laparoscopic cholecystectomy

Background:

Rouviere's sulcus is a 2–5 cm fissure on the liver between the right lobe and caudate process. The benefit of finding the Rouviere's sulcus during laparoscopic cholecystectomy is supported by the fact that the cystic duct and artery lay anterosuperior to the sulcus, and the common bile duct (CBD) lays below the level of the Rouviere's sulcus. Hence, it can serve as an extrabiliary anatomical reference point during laparoscopic cholecystectomy to identify the location of CBD.

Materials and Methods:

This prospective observational study was carried out on 99 patients during a period of 1 year. During laparoscopic cholecystectomy, Rouviere's sulcus was identified after retracting the fundus of the gallbladder toward the right shoulder. Its morphology in terms of open type, close type, or scar-like shapes was recorded, and if the CBD outline could be visualized, then its relation with the Rouviere's sulcus was noted.

Results:

Among all 99 study patients, Rouviere's sulcus could be identified in 63 cases (63.63%), whereas it could not be seen in 36 cases (36.36%) (P < 0.007). It was of open type in 68.25% (43 cases), close type in 25.39% (16 cases), and scar like in 6.35% (4 cases) (P < 0.0001). The Rouviere's sulcus was found to be above the level of CBD line in 50 patients (79.36%) and at the same level in 11 patients (17.46%), and in two patients, (5.97%) CBD line could not be visualized.

Conclusion:

Identification of Rouviere's sulcus during laparoscopic cholecystectomy can serve as an additional reference point to avoid major bile duct injury. In the era of laparoscopy, it can be better visualized after creating the pneumoperitoneum and retracting the fundus of the gallbladder.

A pseudoaneurysm of the right hepatic artery treated successfully with a stent graft - A case report

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Haemobilia caused by pseudoaneurysms of the right hepatic artery or the cystic artery are rare with incidences up to 0.6%.

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Pathogenesis of pseudoaneurysms of the cystic or hepatic arteries are described to be cholecystectomy or cholecystitis related.

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Embolization is considered the golden standard. However, stent grafts should be considered a minimal invasive and effective alternative after failed embolization in pseudoaneurysms.

Introduction

Haemobilia caused by pseudoaneurysms of the right hepatic or cystic artery is rare. Haemobilia classically causes gastro-intestinal hemorrhage, jaundice and upper abdominal pain.

Presentation of case

A 76-year old female underwent laparoscopic cholecystectomy because of a severe acute on chronic cholecystitis. A massive arterial bleeding occurred during surgery, which was controlled with hemoclips. Approximately one week after surgery the patient developed severe colic pains and cholestatic liver enzyme alterations. Endo-ultrasound showed normal-width bile ducts, however during a subsequent ERCP haemobilia was observed. On computed tomography a pseudoaneurysm of the right hepatic artery was seen. Selective embolization was initially successful, however, a rebleed was observed two weeks later and a 6 × 50 mm Viabahn stent graft was placed in the right hepatic artery uneventfully. The patient remained free of complaints during 3-years of follow-up.

Discussion

Pseudoaneurysms of the cystic or hepatic arteries are described to be cholecystectomy or cholecystitis related. The etiology of the pseudoaneurysm in this case can be inflammatory or iatrogenic. Embolization is the golden standard in pseudoaneurysm treatment. Stent graft implantation has not been frequently described as an alternative option to surgery after a failed attempt of embolization.

Conclusion

This case report presents a probable cholecystitis related pseudoaneurysm of the right hepatic artery, which caused haemobilia after cholecystectomy. The pseudoaneurysm was successfully eliminated with a stent graft after embolization had failed. Stent grafts should be considered a minimal invasive and effective alternative after failed embolization of a pseudoaneurysm.

Laparoscopic Management of Gallbladder Duplication: A Case Report

Laparoscopic cholecystectomy has become one of the most commonly performed abdominal surgeries worldwide. Several anatomic variations and congenital malformations in the gallbladder and biliary anatomy have been described. We reported the case of a middle-aged woman who presented with jaundice and abdominal pain. Her laboratory investigations revealed an elevated bilirubin level (mainly the direct component). The patient showed an improvement in the clinical and laboratory parameters after conservative management. Then, the patient was prepared for a laparoscopic cholecystectomy which revealed a duplication of the gallbladder with two distinct cystic ducts draining independently to the common bile duct. The procedure was completed uneventfully. This type of gallbladder duplication is among the least common types. The case highlights the importance of having a meticulous intraoperative evaluation of the biliary anatomy to avoid potential complications and injuries.

Hartmann pouch herniation in Calot's triangle: A case report

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There are many atypical anatomic structural variations of the biliary tree.

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The anatomical variations can be diagnosed either intra-operatively or pre-operatively.

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Surgeon’s experience and knowledge are essential to form the best surgical decision.

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A second opinion of a hepatobiliary surgeon decreases avoidable complex injury to biliary tract in selective cases.

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Fine handling of hepatocystic triangle and skeletonization of porta hepatis are the main principles of surgery.

Introduction

Laparoscopic cholecystectomy is one of the most frequent operations performed around the world. Some pathological findings are particularly rare and difficult to diagnose preoperatively. Here, we report a case of a patient who presented to our hospital with calculus cholecystitis with a unique Intraoperative finding of Hartmann pouch herniation through hepatocystic triangle. The aim of the study is to consider Hartmann pouch herniation as a rare differential diagnosis of gallbladder stone complication.

Presentation of case

We present a 48-year-old male who came to our emergency department complaining of constant epigastric abdominal pain lasting 3 h with vomiting. Utilizing chemistry laboratory studies and radiological studies, the final diagnosis was acute calculus cholecystitis. Early laparoscopic cholecystectomy was done and revealed Hartmann pouch herniation through the Calot’s triangle. This herniation resulted in strangulation of the Hartmann pouch and displacement of the cystic duct and artery anteriorly.

Discussion

The biliary tract is liable for congenital anomalies. These anatomical variations can be diagnosed either intra-operatively or pre-operatively using radiological imaging. Hartmann pouch herniation is a new finding that we encountered in this case.

Conclusion

Profound surgeons’ anatomical knowledge is essential for the safety of patients, especially for hepatobiliary surgeries due to the wide variations in normal and pathological anatomy. Using critical view of safety can decrease avoidable complications. Consulting specialized hepatobiliary surgeon is preferred when dealing with such cases.

Intraoperative detection of aberrant biliary anatomy via intraoperative cholangiography during laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard of treatment for symptomatic cholelithiasis. Although intraoperative cholangiography (IOC) is widely used as an adjunct to LC, there is still no worldwide consensus on the value of its routine use. Anatomical studies have shown that variations of the biliary tree are present in approximately 35% of patients with variations in right hepatic second-order ducts being especially common (15-20%). Approximately, 70-80% of all iatrogenic bile duct injuries are a consequence of misidentification of biliary anatomy. The purpose of this study was to assess the adequacy of and the reporting of IOCs during LC.

METHODS

IOCs obtained from 300 consecutive LCs between July 2014 and July 2016 were analysed retrospectively by two surgical trainees and confirmed by a radiologist. Biliary tree anatomy was classified from IOC films as described by Couinaud (1957) and correlated with documented findings. The accuracy of intraoperative reporting was assessed. Biliary anatomy was correlated to clinical outcome.

RESULTS

A total of 95% of IOCs adequately demonstrated biliary anatomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Bile leaks occurred in two patients who had IOCs (0.73%) and two who did not (7.4%).

CONCLUSION

Surgeons generally demonstrate biliary anatomy well on IOC but reporting of sectoral duct variation can be improved. Further research is needed to determine whether anatomical variation is related to ductal injury.

Preduodenal portal vein: A recipe for disaster during laparoscopic cholecystectomy

We had encountered a very rare congenital anomaly of a preduodenal portal vein while doing laparoscopic cholecystectomy. More significant in our case is that this preduodenal vein is hiding behind omental adhesions with the gallbladder. We want to raise awareness about this very rare anomaly. Recognition and knowledge of this anomaly will prevent the potential of a serious operative misadventure.

Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

Background

Surgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal.

Methods

Sixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors.

Results

The participants performed equally well when presented with a “straight-forward” anatomy [Group A vs. Group B—time sec: 445.5 vs. 496 p = 0.64—NOM: 437 vs. 413 p = 0.88—PL cm: 1317 vs. 1059 p = 0.32—per: 0.5 vs. 0 p = 0.22—NCB: 0 vs. 0 p = 0.71—DVS: 0 vs. 0 p = 0.2]; however, Group B performed significantly better [Group A vs. B Total CAT score—Short Cystic Duct (SCD): 20.5 vs. 26.31 p = 0.02 η² = 0.32—Double cystic Artery (DA): 24.75 vs. 30.5 p = 0.03 η² = 0.28] and committed less errors (Damage to Vital Structures—DVS, SCD: 4 vs. 0 p = 0.03 η²=0.34, DA: 0 vs. 1 p = 0.02 η² = 0.22). in the cases with more challenging anatomies.

Conclusion

These results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

Cystic Artery: Morphological Study and Surgical Significance

The cystic artery is the key structure sought to be clipped or ligated during laparoscopic or conventional cholecystectomy. The possible complications like hemorrhage or hepatobiliary injury are always centered on the search, dissection, and clipping or ligation of the cystic artery, many a time because of possibility of variations in its course and relations to the biliary ducts. This descriptive study was carried out to document the normal anatomy and different variations of the cystic artery to contribute to improve surgical safety. This study conducted on 82 cadavers revealed cystic artery with mean length of 16.9 mm (ranged between 2 mm and 55 mm) and mean diameter of 1.6 mm (range between 1 mm and 5 mm). The origin of cystic artery from celiac right hepatic artery was found in 79.3% and in the remaining 20.7% it was replaced. Single cystic artery was present in 72% and double cystic artery in 28%. Considering the site of origin of the cystic artery with reference to Calot's triangle, it was observed within the triangle in 62.2% and outside it in 37.8%. All the cystic arteries passed through Calot's triangle except for 3.6%. The cystic artery crossed the common hepatic duct anteriorly in 26.8% and posteriorly in 6.1%. It crossed common bile duct anteriorly in 1.2% and posteriorly in 3.7%. The knowledge of such variations and its awareness will decrease morbidity and help to keep away from a number of surgical complications during cholecystectomy.

The clinical anatomy of cystic artery variations: a review of over 9800 cases

PURPOSE

While laparoscopic cholecystectomy can be a routine procedure when biliary anatomy is normally located, cystic artery variations can easily disorientate the inexperienced surgeon to the anatomy of the hepatobiliary triangle. This study presents the clinically important anatomical variations of the cystic artery.

METHODS

PubMed, Medline, Cochrane Database of Systematic Reviews, and Google Scholar databases were searched to conduct a review of the existing English literature on the clinically important cystic artery variations. An aberrant vessel was defined as a vessel that originated from an atypical source and/or one that was present in a specimen in addition to the normal vessel.

RESULTS

The cystic artery originated typically from the right hepatic artery (79.02 %) and was found in the hepatobiliary triangle in only 5427 of 6661 (81.5 %) cases. Clinically important cystic artery variations are (1) the cystic artery located anterior to the common hepatic duct or common bile duct found in 485 of 2704 (17.9 %) and 228 of 4202 (5.4 %) of cases, respectively, (2) the cystic artery located inferior to the cystic duct found in 38 of 770 (4.9 %) of cases, (3) short cystic arteries found in 98 of 1037 (9.5 %) cases and (4) multiple cystic arteries found in (8.9 %) of cases.

CONCLUSION

These variations are common in the general population and can lead to inadvertent ligation of biliary ducts or aberrant vessels. Therefore, it is important for the hepatobiliary surgeon to be aware of these vascular anomalies to avoid operative complications.

Right Hepatic Artery: A Cadaver Investigation and Its Clinical Significance

The right hepatic artery is an end artery and contributes sole arterial supply to right lobe of the liver. Misinterpretation of normal anatomy and anatomical variations of the right hepatic artery contribute to the major intraoperative mishaps and complications in hepatobiliary surgery. The frequency of inadvertent or iatrogenic hepatobiliary vascular injury rises with the event of an aberrant anatomy. This descriptive study was carried out to document the normal anatomy and different variations of right hepatic artery to contribute to existing knowledge of right hepatic artery to improve surgical safety. This study conducted on 60 cadavers revealed aberrant replaced right hepatic artery in 18.3% and aberrant accessory right hepatic artery in 3.4%. Considering the course, the right hepatic artery ran outside Calot's triangle in 5% of cases and caterpillar hump right hepatic artery was seen in 13.3% of cases. The right hepatic artery (normal and aberrant) crossed anteriorly to the common hepatic duct in 8.3% and posteriorly to it in 71.6%. It has posterior relations with the common bile duct in 16.7% while in 3.4% it did not cross the common hepatic duct or common bile duct. The knowledge of such anomalies is important since their awareness will decrease morbidity and help to keep away from a number of surgical complications.

Innovative Approach to a Frozen Calot's Triangle During Laparoscopic Cholecystectomy

The laparoscopic cholecystectomy is now the "gold standard." In around 2 % of cases, there is a need to convert because of the difficult dissection encountered in the Calot's Triangle, a "frozen Calot's triangle." There is no consensus among surgeons about how to tackle this situation. To lower the conversion rate, there is a continuous attempt made to innovate. The authors present their rationale and experience in 100 difficult cases by creating a retro-gallbladder tunnel and encircling the gallbladder by a gauze for maneuvering.

Augmented reality visualization of deformable tubular structures for surgical simulation

BACKGROUND

Surgical simulation based on augmented reality (AR), mixing the benefits of physical and virtual simulation, represents a step forward in surgical training. However, available systems are unable to update the virtual anatomy following deformations impressed on actual anatomy.

METHODS

A proof-of-concept solution is described providing AR visualization of hidden deformable tubular structures using nitinol tubes sensorized with electromagnetic sensors. This system was tested in vitro on a setup comprised of sensorized cystic, left and right hepatic, and proper hepatic arteries. In the trial session, the surgeon deformed the tubular structures with surgical forceps in 10 positions.

RESULTS

The mean, standard deviation, and maximum misalignment between virtual and real arteries were 0.35, 0.22, and 0.99 mm, respectively.

CONCLUSION

The alignment accuracy obtained demonstrates the feasibility of the approach, which can be adopted in advanced AR simulations, in particular as an aid to the identification and isolation of tubular structures. Copyright © 2015 John Wiley & Sons, Ltd.

Dual Cystic Arteries in Association with Caterpillar Hump of Right Hepatic Artery- A Case Report and its Surgical Relevance

A rare variation was seen in the arterial supply of liver and gall bladder during dissection of an adult female cadaver. The right hepatic artery was having a tortuous course with double loops and cystic artery was arising from the distal loop within the hepatobiliary triangle. There was an accessory cystic artery arising from the superior pancreaticoduodenal artery outside the hepatobiliary triangle which ascended anterior to the common bile duct and cystic duct towards the gall bladder. The knowledge of these vascular variations is very much essential owing to increase in surgical interventions involving the biliary tract. Recognition of such vascular variations is essential for laparoscopic surgeons to reduce complications like uncontrolled intraoperative bleeding, iatrogenic extrahepatic biliary injuries and conversion to open cholecystectomy. This report emphasizes the necessity of all surgeons being well aware of vascular variations and anomalies to be able to accomplish safe and uneventful hepatobiliary surgeries.

Anatomy and surgical relevance of Rouviere's sulcus

Rouviere's sulcus (RS) (i.e., incisura hepatis dextra, Gans incisura) represents an important anatomical landmark. The aim of the study was to determine the frequency of the RS, its description, its location, its relations to the right portal pedicle and to the plane of the common bile duct, and the evaluation of the surgical relevance of the obtained data. Forty macroscopically healthy and undamaged livers were removed during autopsies from cadavers of both sexes. The RS was present in 82% of the cases and in these the open RS was identified in 70% of the livers. The fused type was observed in 12% of the cases; 18% of the livers had no sulcus. The mean length of the open type RS was 28 ± 2 mm (range 24-32 mm) and its mean depth was 6 ± 2 mm (range 4-8 mm). The right posterior sectional pedicle was found in the RS in 70% of the cases. In 5% of the livers, we also dissected a branch of the anterior sectional pedicle. Inside 25% of the RS, we found the vein of segment 6. The RS identification may avoid bile duct injury during laparoscopic cholecystectomy and enables elective vascular control during the right liver resection.

Singapore's anatomical future: quo vadis?

The disciplines of anatomy and surgery are not dichotomous since one is dependent on the other. Traditionally, surgeons predominantly taught gross and clinical anatomy. In this review, we examine the context of how human anatomy is taught nowadays. In essence, we discovered that there are certain discernable trends consistently observable between the American and British systems. In Singapore, the British Russell Group first influenced its education landscape but now more so by the American Ivy League. Singapore now has three medical schools all offering differing anatomy curricula, which serves as an opportune time for it to consider if there is a best approach given that the practice of surgery is also evolving in parallel. This review discusses the various pedagogies and issues involved, and will serve as a forum and stimulus for discussion. By tweaking the curriculum correctly and the lessons learnt, future doctors and surgeons in training will receive a better anatomical education, not just in Singapore but the world in general. Key recommendations include the use of body painting, clay, plasticine to facilitate the learning of anatomy, and the implementation of a body donation program. Furthermore, strategic mergers with key stakeholders will also ensure the survival of the discipline.

Critical view of safety during laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Laparoscopic cholecystectomy has a 0.3% to 0.5% morbidity rate due to major biliary injuries. The majority of surgeons have routinely performed the so-called "infundibular" technique for gallbladder hilar dissection since the introduction of laparoscopy in the early nineties. The "critical view of safety" approach has only been recently discussed in controlled studies. It is characterized by a blunt dissection of the upper part of Calot's space, which does not usually contain arterial or biliary anomalies and is therefore ideal for a safe dissection, even in less experienced hands.

MATERIALS AND METHODS

We applied and compared the critical view of safety triangle approach with the infundibular approach in a retrospective cohort study. We divided 174 patients into 2 groups, with a similar case-mix (cholelithiasis, chronic cholecystitis, and acute cholecystitis). Results of operations performed by a young surgeon using critical view of safety dissection were compared to results of the infundibular approach performed by an experienced surgeon. Outcome values and operative times were examined with univariate analysis (Student t test).

RESULTS

No difference occurred in terms of morbidity (even though comparison for biliary injuries is inconclusive because of insufficient power) and outcome; significant differences were found in operative time, favoring the critical view of safety approach in every stage of gallbladder disease, with minor significance for acute cases.

CONCLUSION

We suggest this technique as the gold standard for resident teaching, because it has a similar rate of biliary and hemorrhagic complications but has a shorter operative time, builds self-confidence, and is a simple standardized method both for complicated and uncomplicated gallbladder lithiasis.