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World J Gastrointest Surg. Feb 27, 2019; 11(2): 62-84
Published online Feb 27, 2019. doi: 10.4240/wjgs.v11.i2.62
Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy
Vishal Gupta, Gaurav Jain
Vishal Gupta, Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George’s Medical University, Lucknow 226003, Uttar Pradesh, India
Gaurav Jain, Transplant and HPB Surgery, the Iowa Clinic-Iowa Methodist Hospital, Des Moines, IA 50309, United States
Author contributions: Gupta V reviewed the literature, conceptualized, drafted and critically revised the manuscript and generated figures; Jain G contributed figures and drafted and critically revised the manuscript.
Conflict-of-interest statement: There is no conflict of interest associated with any of authors contributed their efforts in this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Vishal Gupta, MBBS, MS, MCh, Professor, Surgeon, Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George's Medical University, King George’s Medical University, Lucknow 226003, Uttar Pradesh, India. vggis@yahoo.co.in
Telephone: +91-885-3100915 Fax: +91-522-2256116
Received: November 12, 2018
Peer-review started: November 14, 2018
First decision: November 29, 2018
Revised: January 6, 2019
Accepted: January 23, 2019
Article in press: January 23, 2019
Published online: February 27, 2019
Abstract

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

Keywords: Bile leak, Bile duct injury, Cholecystectomy, Cholelithiasis, Cholecystitis

Core tip: Laparoscopic cholecystectomy (LC) is associated with higher risk of biliary injury. This complication is associated with prolonged morbidity, decreased overall survival and potential for litigation. Prevention remains the best strategy. With the understanding of underlying mechanisms related to this complication, a number of preventive strategies have been described. Besides proper training and use of optimal equipment, understanding relevant anatomy, identification of factors predicting difficult procedure, execution of correct surgical technique, use of the critical view of safety, judicious use of energy sources, understanding stopping rules, time-out and bailout techniques, and proper documentation are basic tenets of safe LC.