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A Safe Stepwise Approach to the Critical View of Safety During Laparoscopic Cholecystectomy

Contributors: Eric Zimmerman and Pierre F Saldinger

After the introduction of laparoscopic cholecystectomy bile duct injury rates have increased (3 per 1,000 cholecystectomies). Bile duct injuries after cholecystectomies are unfortunate events that can lead to significant morbidity, high cost and impair in quality of life. The purpose of this video is to demonstrate a safe stepwise approach to the critical view of safety described by Strasberg during laparoscopic cholecystectomy.

DOI: http://dx.doi.org/10.17797/ce9i07jf03

Editor Recruited By: Jeffrey B. Matthews, MD

The procedure starts with a standard laparoscopic port placement starting with an open umbilical technique using a Hassan trocar. Three 5mm trocars are subsequently placed on the epigastrium and right upper quadrant. The pneumoperitoneum is achieved. After adequate retraction of the gallbladder the operative surgeon will focus on an imaginary ¢Y¢shaped line that divides the cystic duct and artery and continues towards the gallbladder infundibulum. In this case the hepatic artery was unusually present in the dissection field. The goal is to create the space between this two structures staying as close as possible to the gallbladder away from the common bile duct. The dissection is carried out in a vertical fashion with an ¢L¢ shape monopolar electrocautery. In this case the cystic artery was short and small and was cauterized with the monopolar instrument. The angle between the cystic duct and the gallbladder is further dissected to create a free passage of the instrument as high as possible. The critical view is created. And Calot's triangle is identified. The cystic duct is clipped and divided and the cholecystectomy is completed in a standard fashion
Symptomatic cholelithiasis
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1. -Buddingh KT, Weersma RK, Savenije RA, van Dam GM, Nieuwenhuijs VB. Lower rate of major bile duct injury and increased intraoperative management of common bile duct stones after implementation of routine intraoperative cholangiography. Journal of the American College of Surgeons 2011; 213:267-74 2. -Kern KA. Malpractice litigation involving laparoscopic cholecystectomy. Cost, cause, and consequences. Archives of Surgery 1997; 132:392-7; discussion 7-8 3.- Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. Journal of the American College of Surgeons 2010; 211:132-8

Review A Safe Stepwise Approach to the Critical View of Safety During Laparoscopic Cholecystectomy.

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