Protocol for laparoscopic cholecystectomy: Is it rocket science?

Table 1 Mandatory protocol to avoid unexpected injuries during laparoscopic cholecystectomy

Consideration that a high level of experience alone is not adequate for successful laparoscopic cholecystectomy

Biliary injuries are principally caused by misperception, not from insufficient skill, lack of knowledge, or misjudgment

Misidentification is the result of failure to conclusively identify the cystic structures and is secondary to the surgeons’ assumptions during LC

Recognition of the plateau involving the CHD and hepatic hilum

Stretch the hepatoduodenal ligament and confirm the left sagittal fissure

A U-shaped line is visually traced from the round ligament of the liver to the left side of the GB

The bottom plateau of this U-shaped line necessarily involves the CHD and hepatic hilum

Blunt dissection until CVS exposure

During clearance of Calot’s triangle, the dissectable/cuttable layer should be traced as close to the GB and CD as possible

Tissue dissection and membrane cutting should be extended from the apparent side, not from the unknown side

Never use any sealing devices until CVS exposure

Calot’s triangle clearance in the overhead view

Hartmann’s pouch should be pulled laterally and inferiorly to open the anterior left side of Calot’s triangle

A wider angle between the CD and CHD is created

The anterior left side of Calot’s triangle is exposed and dissected

Calot’s triangle clearance in the view from underneath

The hepatorenal fossa is widely dilated, and Hartmann’s pouch is confirmed.

Superior and medial traction of the GB infundibulum or Hartmann’s pouch is performed

The S-like curve on Hartmann’s pouch, GB infundibulum, IC junction, and CD is confirmed

The IC junction is confirmed as an inverted V shape due to superior and medial traction of the GB

Dissection of posterior right side of Calot’s triangle in the rightward and upward view

Cutline of membrane is made to the GB body at a point adequately distant from Rouviere’s sulcus

The posterior right side of Calot’s triangle is exposed and dissected

The GB wall and fatty fissure of Rouviere’s sulcus should be uncoupled

Dissectable tissue around the GB should never be followed into Rouviere’s sulcus

Removal of half to two-thirds of GB body from the LB

Half to approximately two-thirds of the GB body is removed from the LB at the CVS exposure

Positive accomplishment of the CVS exposure

Only two cystic structures should be seen entering the GB

CD: Cystic duct; CHD: Common hepatic duct; CVS: Critical view of safety; GB: Gallbladder; IC: Infundibulum-cystic duct; LB: Liver bed; LC: Laparoscopic cholecystectomy.