Protocol for laparoscopic cholecystectomy: Is it rocket science?

Figure 3 Tips and pitfalls of laparoscopic cholecystectomy. A: Adequate retraction is performed for the laparoscopic view from underneath (blue arrow). Confirmation of the S-like curve on Hartmann’s pouch, infundibulum, IC junction, and CD is important (red line); B: The IC junction is confirmed as an inverted V shape (red line) because of the superior and medial traction of the GB (blue arrow); C: The cutline of the membrane is made to the GB body at a safe distance from Rouviere’s sulcus (red arrow). Adequate retraction is performed (blue arrow); D: Dissectable tissue around the GB should never be followed into Rouviere’s sulcus. Uncoupling of the GB wall and fatty fissure of Rouviere’s sulcus is important to avoid any biliary injuries. Adequate retraction is performed (blue arrow); E: Approximately two-thirds or half of the GB body is removed from the LB in the overhead view. A dissectable/cuttable layer is cut by L-hook electrocautery (red arrow) under adequate retraction (blue arrow), as close to the GB as possible; F: Approximately two-thirds or half of the GB body is removed from the LB in the view from underneath with adequate retraction (blue arrow). The dissectable/cuttable layer (dotted circle) is cut as close to the GB as possible using the L-hook electrocautery technique (red arrows); G: The CVS is ventrally confirmed (red arrow) under counter-retraction (blue arrow). Approximately two-thirds or half of the GB body is removed from the LB. Rouviere’s sulcus is far from the CD and GB; H: The CVS is dorsally confirmed (red arrow) under counter-retraction (blue arrow). Approximately two-thirds or half of the GB body is removed from the LB. Rouviere’s sulcus is located far from the CD and GB. The U-like line from the round ligament of the liver to the left side of the GB is visually traced (dotted line). CD: Cystic duct; CHD: Common hepatic duct; CVS: Critical view of safety; GB: Gallbladder; IC: Infundibulum-cystic duct; LB: Liver bed; LC: Laparoscopic cholecystectomy.